1. Art and Diseño

FEBRUARY 2015 • VOL. 16, NO. 2
www.CaringfortheAges.com
™
AN OFFICIAL PUBLICATION OF
AMDA – THE SOCIETY FOR
POST-ACUTE AND LONG-TERM
CARE MEDICINE
Caringfor the Ages
A Monthly Newspaper for Long-Term Care Practitioners
COPD Treatment Improves Quality of Life
Dear Dr. Jeff
Residents with swallowing issues
present a conflict between
protecting them and respecting
their desire to assert control. ..... 3
The Write Stuff
Louise Aronson, MD, MFA, urges
PA/LTC practitioners to tap into
their inner writers, speakers, and
artists. She will give the Anne-Marie
Filkin Lecture at AMDA’s annual
conference next month. ..........4
ACOs in Post-Acute Care
Accountable care organizations
put skilled nursing facilities under
the magnifying glass. ............. 12
BY CHRISTINE KILGORE
M
anaging chronic obstructive
pulmonary disease in the nursing
home entails not only reducing
the exacerbations and flares that make
the disease a leading cause of hospitalization and hospital readmissions but also
reducing the symptoms that can make
the illness a daily struggle. These goals
largely go hand-in-hand.
“COPD is one of the few diseases where
patients are prone to be very symptomatic on a daily basis, with a high daily burden of discomfort,” said Gerard J. Criner,
MD, professor of medicine at the Temple
University School of Medicine and director of the Temple Lung Center at the
university’s hospital in Philadelphia.
Approximately one-fifth of nursing
home residents had a diagnosis of COPD
in one recent study. Individuals with the
disease face a complex assault on the
lungs – often involving emphysema or
chronic bronchitis and sometimes refractory asthma – that causes airflow blockage and problems with breathing. In
2011, the Centers for Disease Control
and Prevention reported that chronic
lower respiratory tract disease, primarily COPD, had become the third leading
cause of death in the United States, after
heart disease and cancer.
The optimization of drug therapies is
at the heart of treatment for COPD, and
therein lies a main challenge for nursing
homes with many frail elderly residents.
Treatment for anything but mild COPD
with intermittent symptoms should
involve long-acting inhaled beta-agonists
HAMILTON
Better Vision Aids Cognition
Expert cautions that hidden visual
deficits can masquerade as hidden
cognitive deficits in patients with
Alzheimer’s. ............................... 2
© ISTOCKPHOTO . COM / KIRBY
In This Issue
Chronic lower respiratory tract disease trails only heart disease and cancer as
the third leading cause of death in the United States.
or anticholingeric medication, which
entails regular use of an inhaler or a
nebulizer, and often inhaled corticosteroids as well.
Drug treatment cannot restore lung
function, but it can change the trajectory
of disease, ease its symptoms, and help
to reduce the frequency and severity of
exacerbations. Treatment can be empiric
and should be guided largely by holistic,
patient-focused outcomes like quality
of life, tolerability of the medication,
and general functionality, rather than by
quantitative measures of lung function,
sources say.
“What the GOLD [Global Initiative
for Chronic Obstructive Lung Disease]
guidelines tell us is that when patients
are very limited by COPD, it’s important that they be [effectively] medicated,”
said Trina M. Limberg, director of
Pulmonary and Rehabilitative Services
at the University California San Diego
Health System.
See COPD • page 8
Medicaid Managed Care Lifts Barriers to Home Care
B Y J O A N N E K A L DY
J
ust when post-acute/longterm care practitioners got
used to the Affordable Care
Act, accountable care organizations, and quality assurance
and performance improvement, along comes another
new complicated initiative to
wrap their minds around –
managed long-term services
and supports. MLTSS includes
state programs that deliver
long-term care services and
supports through capitated
managed care plans. Also
known as Medicaid managed
care, MLTSS represents a move
from traditional fee-for-service
payment systems as a way to
control costs, increase efficiency, and enable more people to
minimize their stays in PA/LTC
facilities and return to their
homes as quickly as possible
after an injury or illness.
Not all states currently have
MLTSS programs, but they are
becoming more prevalent. Only
eight states had Medicaid managed care programs in 2004. By
2012, that number had grown
to 16; currently about 30 states
have Medicaid managed care
programs, and the number is
still growing. Participation in an
MLTSS program is mandatory
in some states and voluntary
in others, although more states
Save $300
on AMDA’s 2015 Annual Conference
are requiring Medicaid beneficiaries to enroll in some form
of managed care.
According to federal regulations overseeing managed care
delivery systems, a Medicaid
managed care plan must have
consumer protections in place,
See Home Care • page 17
+ Save $400
on the 2015 Webinar Bundle
Become an AMDA member today www.amda.com/membership/
™
2 • CARING FOR THE AGES
FEBRUARY 2015
Cataract Surgery May Slow Cognitive Decline
BY CHRISTINE KILGORE
Vision with cataract.
P HOTOS
PROPERTY OF
Normal vision.
G ROVER C. G ILMORE , P H D, C ASE W ESTERN R ESERVE U NIVERSITY
C
ataract surgery not only improves
visual acuity in individuals with
Alzheimer’s disease and other
dementias – it also appears to slow
cognitive decline and improve neuropsychiatric symptoms, according to preliminary results from an ongoing study.
An initial analysis comparing 28 surgical and 14 nonsurgical patients – about
a third of whom were nursing home
residents – is currently being expanded.
“If these results hold up (with a larger
study population), we will definitely
see changes in practice,”Alan Lerner,
MD, professor of neurology at Case
Western Reserve University School
of Medicine, who presented the findings at the Alzheimer’s Association
International Conference 2014, told
Caring for the Ages.
Currently, there is “tremendous
reluctance and ambivalence” toward
treating comorbidities in patients with
Alzheimer’s and other dementias,” he
said.
Yet the findings – including improvements on the Mini-Mental State Exam
(MMSE) and the Neuropsychiatric
Inventory (NPI) among surgical
patients – demonstrate that “improving
vision is a clear quality-of-life issue” for
these individuals, said Dr. Lerner.
“Yes, Alzheimer’s is a brain disease,
but we have to look at the whole person.
There are other factors, including vision,
that affect cognition,” he said. “And the
effect of visual improvement on [behavior] – it’s huge.”
Cataracts can be even more troublesome in individuals with Alzheimer’s
than in those without the disease.
Grover C. Gilmore, PhD, professor of
psychology and social work, and dean
of the Jack, Joseph and Morton Mandel
School of Applied Social Services at Case
Western Reserve, has shown in other
research that patients with Alzheimer’s
Vision with Alzheimer’s disease.
disease commonly experience significant declines in contrast sensitivity in as
little as 6 months after their diagnoses –
impairments that he said may result
from cellular disease-related changes in
the vision system.
“When you put a cataract on top of
this, it becomes [even more serious],”
said Dr. Gilmore, the study’s lead
investigator.
Patients included in the current study
of cataract surgery met the criteria for
Alzheimer’s disease or other neurodegenerative dementias and had at least
one visually significant cataract. They
either had surgery following enrollment and baseline testing (intervention
group), or refused or delayed surgery
(the control group).
At 6 months, scores on the MMSE
had improved by a mean of 0.39 points
in the intervention group and declined
by a mean of 2.31 points in the control
™
Editor in Chief Karl Steinberg, MD, CMD
EDITORIAL ADVISORY BOARD
Chair: Karl Steinberg, MD, CMD, California
Robin Arnicar, RN, West Virginia
Nicole Brandt, PharmD, CGP, BCPP, FASCP, Maryland
Ian L. Cordes, MBA, Florida
Jonathan Evans, MD, CMD, Virginia
Janet Feldkamp, RN, JD, BSN, Ohio
Robert M. Gibson, PhD, JD, California
Daniel Haimowitz, MD, FACP, CMD, Pennsylvania
Linda Handy, MS, RD, California
Jennifer Heffernan, MD, CMD, Texas
Bill Kubat, MS, LNHA, South Dakota
Jeffrey Nichols, MD, New York
Dan Osterweil, MD, CMD, California
Barbara Resnick, PhD, CRNP, FAAN, FAANP, Maryland
Dennis L. Stone, MD, CMD, Kentucky
AMDA headquarters is located at 11000 Broken Land Parkway,
Suite 400, Columbia, MD 21044.
Vision with Alzheimer’s disease and
cataract.
group. The average annual rate of
change in MMSE scores in this population is 2-3 points, Dr. Lerner said.
As important – if not more – was
a decline in the NPI, which assessed
anxiety, confusion, depression, and other
symptoms. The mean change in the NPI
was -4.91 among individuals who had
cataract surgery and +3.92 among those
who declined or delayed the surgery.
Caregivers also benefited from cataract surgery. Caregiver distress as measured by the NPI Caregiver Distress
scale declined in the intervention group
and increased in the control group.
Cognitive function was assessed with
the Alzheimer’s Disease Assessment
Scale-cognitive subscale (ADAS-cog) as
well as the MMSE, but the investigators
found only “trending” differences in the
6-month ADAS-cog scores rather than
a clear reduction in cognitive decline
after surgery – a finding that Dr. Lerner
attributed to the small size of the study.
Unease with cataract surgery in
patients with Alzheimer’s disease and
other dementias often involves concern
about anesthesia and the general stress
of undergoing a procedure, but consideration of safety and risks must be better
balanced with attention to the benefits,
Dr. Lerner said.
“In Alzheimer’s disease,” said
Dr. Gilmore, “hidden visual deficits can
masquerade as hidden cognitive deficits.
One reason (individuals with the disease) do poorly in neuropsychological
tests is that they can’t see very well.
‘If you want to know
what the world looks
like to patients with
Alzheimer’s disease, put
on two pairs of heavy
sunglasses and squint.’
“If you want to know what the world
looks like to patients with Alzheimer’s
disease, put on two pairs of heavy sunglasses and squint,” he said.
When cataracts are diagnosed, surgical
intervention can “benefit vision, cognition, and quality of life,” Dr. Gilmore said.
Other ocular comorbidities that can
affect vision – such as macular degeneration and end-stage glaucoma – should be
ruled out by an ophthalmologist before
cataract surgery is seriously considered,
Dr. Lerner noted.
The study was funded by the National
Institute on Aging. Participants were
recruited from the University Hospitals
Case Medical Center and MetroHealth
Medical Center.
CfA
Christine Kilgore is a freelance writer
based in Falls Church, VA.
Caringfor the Ages
CARING FOR THE AGES is the official newspaper of AMDA – The Society for
Post-Acute and Long-Term Care Medicine and provides long-term care
professionals with timely and relevant news and commentary about
clinical developments and about the impact of health care policy on
long-term care. Content for CARING FOR THE AGES is provided by AMDA
and by Elsevier Inc.
The ideas and opinions expressed in CARING FOR THE AGES do not necessarily
reflect those of the Association or the Publisher. AMDA and Elsevier
Inc., will not assume responsibility for damages, loss, or claims of
any kind arising from or related to the information contained in this
publication, including any claims related to the products, drugs, or
services mentioned herein.
©2015 AMDA – The Society for Post-Acute and Long-Term Care Medicine.
CARING FOR THE AGES (ISSN 1526-4114) is published monthly by Elsevier Inc.,
360 Park Avenue South, New York, NY 10010. Business and Editorial
Offices: Elsevier Inc., 360 Park Avenue South, New York, NY 10010.
Accounting and Circulation Offices: Elsevier Health Sciences Division,
3251 Riverport Lane, Maryland Heights, MO 63043. Periodicals postage
paid at New York, NY and additional mailing offices.
POSTMASTER: Send change of address to CARING FOR THE AGES, Elsevier,
Elsevier Health Sciences Division, Subscription Customer Service, 3251
Riverport Lane, Maryland Heights, MO 63043. Subscription price is
$219.00 a year (individual).
EDITORIAL OFFICES 1600 JFK Blvd., Suite 1800, Philadelphia PA, 19103,
215-239-3900, fax 215-239-3990. Letters to the Editor: caring@
elsevier.com
EDITORIAL STAFF
Managing Editor Carey Cowles
Senior Contributing Writer Joanne Kaldy
Social Media Editor Lindsey Neal, MD
Display Sales Manager Carol Clark 212-633-3719,
[email protected]
Classified Advertising Adam Moorad 212-633-3122,
[email protected]
Customer Service Orders, claims, online, change of address:
Elsevier Periodicals Customer Service, 3251 Riverport Lane, Maryland
Heights, MO 63043; telephone (800) 654-2452 (United States
and Canada), (314) 447-8871 (outside United States and Canada);
fax: (800) 225-4030 (United States and Canada), (314) 447-8029
(outside United States and Canada); e-mail: [email protected] (for print support); JournalsOnlineSupport-usa@
elsevier.com (for online support). Address changes must be submitted
four weeks in advance.
CARING FOR THE AGES •
CARINGFORTHEAGES.COM
Dear Dr. Jeff
3
By Jeffrey Nichols, MD
Aspiration Risks Can Make Meals Hard to Swallow
Dear Dr. Jeff:
We have an ongoing concern at our facility
on where to draw the line between patient
rights and safety, especially with feeding
issues. We serve the disabled and have residents with spinal injuries, head injuries,
cerebral palsy, etc. Many of these residents
have swallowing issues and are at high risk
for aspiration. Many also have the competence and the capacity to make decisions.
Although we would refuse to give a resident
on a level 1 diet a level 4 diet due to safety
issues, we do give many a level 2 diet on the
grounds of patient rights and quality of
life. Another concern is those who request to
eat with their doors closed or who want to
eat and take medications at less than a 45°
incline. I would appreciate your insights into
these issues.
Dr. Jeff responds: Your question combines one of the most difficult questions
in long-term care medicine with some
of the most important but also most
difficult questions in medical ethics. Still,
it is commendable that you and your
facility recognize this is even a problem.
The phrase “at high risk for aspiration”
seems clear, but contains a series of traps.
First, essentially all human beings are
at risk for aspiration. The average adult
has an episode of food “going down the
wrong way” once or twice a year, and a
single episode of food penetrating the
upper airway (aspiration) could progress
to the feared sequelae of aspiration pneumonia or death from airway obstruction
(the “café coronary”).
Secondly, most long-term residents
meet common criteria for being “at risk,”
which include moderate to advanced
dementia; history of stroke, Parkinson’s
disease, or other neurologic conditions
likely to affect upper airway sensory or
motor function; history of head and
neck cancer; history of pneumonitis in
the past year; wet voice; coughing during or after meals; and the use of medications known to decrease swallowing
ability or saliva production. Thirty years
ago, when the interest in dysphagia was
still in its infancy, my facility used those
criteria to screen all our residents with
the intention to formally evaluate our atrisk population. Our data (later presented
at a Johns Hopkins Annual Dysphagia
Seminar) showed that 90% were at risk.
Since that time, nursing home populations have become even more frail.
The ability of clinicians to identify
and evaluate the degree of risk remains
surprisingly limited. The medical literature invariably asserts that collaborative
video studies of swallowing performed
in a radiology suite by a radiologist
and speech therapist or occupational
therapist (modified barium swallow studies) represent the gold standard for dysphagia evaluation. Yet dementia patients
brought to an unfamiliar location and
fed a chalky substance by strangers are
rarely totally cooperative with testing.
And although these studies are generally
performed during the daytime, nursing
home residents are typically at their best
during the morning, and often become
weaker and more confused as the day
progresses. Flexible endoscopic evaluation of swallowing actually might be a
preferable test for many nursing home
residents. It allows better compliance
because feedings are genuine facility
food, performed in familiar surroundings by familiar staff. Clinical evaluations
by speech language pathologists working collaboratively with direct care staff
are also very useful and may be individualized to the patient and his or her needs.
For example, alternate feeding positions
can be tested, such as varying degrees of
bed elevation.
Real-Life Risks
Unfortunately, all the above tests do not
reproduce real life. For example, swallowing function may vary with flavor.
One article identified significant differences in tongue motor function among
water and variously flavored liquids ( J
Speech Lang Hear Res 2012;55:262-75).
Also, foods of similar consistency, particularly those that are part of a regular diet, may represent significantly
different risks. Peanuts are particularly
dangerous.
I was the medical director of a large
facility that annually held a celebration
they called a July 4th party, but it should
have been called the Heimlich Bowl. Local
firemen held a large picnic to honor veterans at which they served beer and hot
dogs. The combination of alcohol, soft
bread, and a firm round piece of meat
is ideal for upper airway obstruction. A
good year meant that we rescued everyone without a hospital transfer. Many of
the Heimlich survivors were front and
center every year. How do you balance
the risk of death against the pleasure of
the quintessential American event?
Finally, most discussions of swallowing function focus on aspiration as an
endpoint. However, a demonstration
that food or fl uids enter the upper
airway is essentially an anatomic concept – a condition, rather than a disease.
Many residents routinely have material
enter the trachea but are able to clear
it, whether through the post-deglutition cough or via the action of the cilia
that beat mucus and trapped materials
upward from the lung. These residents
may suffer some discomfort from the
coughing but will not necessarily go on
to aspiration-related bronchitis or pneumonitis. Alternately, the actual volume
of material aspirated may be more significant than the simple fact that something entered the upper airway.
The diet levels in your question are
from the National Dysphagia Diet, created in 2002 by the American Dietetic
Association so that dieticians can discuss diet consistencies in similar terms,
and as a basis for research. They were
never scientifically validated and have
not been accepted by the American
Speech-Language-Hearing Association
as terminology, much less as a basis for
clinical treatment guidelines.
Moreover, regardless of prescribed
diet consistencies, all residents continuously produce saliva, which is routinely
swallowed between meals and at night.
Consequently, many programs designed
to prevent aspiration pneumonia concentrate on improved oral hygiene,
which is definitely a modifiable risk factor, rather than on dysphagia as such.
They also modify medication regimens,
because antipsychotics and sedatives significantly increase the risk of aspiration
pneumonia. Ironically, anticholinergic
medications that decrease salivation
actually increase pneumonia risk, perhaps because of their adverse effects on
cognitive function.
Who Decides What Is Best?
Informed consent occurs when a
patient assesses the risks and benefits
of a potential action or series of actions.
Decision-making capacity is the ability to evaluate these risks and benefits
to form and express a rational choice.
The risks involved in many choices are
relatively trivial, such as which clothing to wear, where the worst choice
might only produce an unflattering outfit. Many ethicists point to the concept
of autonomy as the central principle
of modern medical ethics. The right
to make decisions for ourselves often
trumps other considerations, such as the
desire of LTC professionals to provide
Share Your
Story
Do you have a story about patient
mealtime issues? Caring for the
Ages will be focusing on aspiration,
swallowing, and other feeding concerns in an upcoming issue. Please
contact Carey Cowles, managing
editor, at [email protected] for
more information.
a safe environment and preserve the
health of those under our care. But the
real confl ict here is not between the
concerned caregiver and some legalistic notion of resident rights, but rather
between a desire to protect the resident
and the need to respect the resident as
another human being. It is, essentially,
the Golden Rule. This would, in my
opinion, extend to choices involving
food consistency, the thickness of liquids, the type of food, or the location
and position in which food is consumed.
Certainly, the resident who is uncomfortable or in frank pain when placed in
an “ideal” location, or when the head
of his/her bed is raised above a certain
level, should be allowed to weigh that
negative against the increased risk of
aspiration in a preferred position.
Unfortunately, this process becomes
more confusing when the professionals have great difficulty quantifying the
risks of various swallowing conditions.
Similarly, the efficacy of our solutions to
these problems seems more conjectural
than scientific. Even such well-established maneuvers as chin-tucking have
been found in several studies to have limited benefit. Under these circumstances,
the preference of the patient should certainly be the deciding factor.
If our own understanding of resident
risks and burdens is limited, this suggests that residents have rarely been presented with the details of their dysphagia
and the reasoning behind our concerns.
Many residents yearn for a different
physical condition, which often means
that they do not know the full extent of
their disability. All too often, residents
have simply been told that they have difficulty swallowing or failed a barium swallow with little explanation of what that
means. The resident may understand the
obvious benefits of their choice without
fully understanding the risks.
Unfortunately, in the world of longterm care, there is a never-ending need
to document. The reasons behind resident requests for risky behaviors should
be explored and addressed. Why would a
resident wish to eat in his/her own room
with the door closed? Could the desire
for privacy be addressed in another way?
Does this represent depression, paranoia, or simply embarrassment caused
by drooling or use of a bib? Are less risky
alternatives available that still meet resident concerns? Or does this represent an
effort by a powerless resident to exert
some control over their life?
You should certainly document your
warnings regarding the nature and
See Aspiration Risks • page 5
4 • CARING FOR THE AGES
FEBRUARY 2015
Filkin Lecturer Explores the Creative Process
Creativity Blockers
Although most people have some ability
to express themselves, said Dr. Aronson,
“Some practitioners channel their creativity into their work as clinicians,
researchers, educators, etc. And they
get creative satisfaction from this work.”
Others, she said, may have a desire to be
creative but draw a strict line between
their professional and personal selves, so
they don’t pursue creative outlets professionally. Still others may have the desire
but lack the confidence or the focus. “It
can be hard to know where to start, and
it can be easy to compare yourself with
others and feel inadequate,” she said.
‘One of the best ways to
get moving is to not have
a goal but to be excited
about a story or an idea.’
To get past these barriers, Dr. Aronson
suggested putting aside what others do
or think and just getting started. “One
of the best ways to get moving is to not
have a goal but to be excited about a
story or an idea. Then just pour it out
and communicate your message – like
you’re writing a letter to a good friend.”
To avoid getting hung up on crafting the
perfect wording, Aronson suggested, “If
you’re working on a computer, turn off
the monitor so you can’t see what you’re
typing. Or you can dictate your ideas
into a phone or recorder.”
Some people have fears about the critiques and reviews that are inevitable
Why Bother?
Starting or engaging in conversations
about health care, especially post-acute
and long-term care, is a valuable and
much needed endeavor. “Long-term care
is a best kept secret,” Dr. Aronson said.
“We have so much experience and expertise that helps so many people. People
can gain a better understanding of our
field from our writing and speaking
about it. The result can be young practitioners entering the field and patients
getting better care because of what we
write and say. It can help educate students about an area of practice they previously didn’t know much about.”
The practitioner’s writings also can
encourage informed, engaged patients
and families. “Our writing can help start a
dialogue with patients and families that is
different from the conversations we have
in the clinical setting,” she said. “These
conversations can result in more informed
consumers and can transform care.”
Getting Started
Make a commitment to write for 5 minutes every day for a few weeks, said
Dr. Aronson, and then “see what you
have. You might be surprised how much
you can accomplish in a short time. At
the very least, you will have put your
passion into words, and this is a great
starting point since it’s easier to work
with something than to stare at a blank
page or screen.”
The Internet is another good place to
start. Dr. Aronson discussed the value
of social networking as a platform for
words and ideas. “I only got started on
Twitter because I was told I must to promote my book. It was a little confusing
at first, but it’s kind of fun once you get
the hang of it, and it has transformed my
medical career.” She added, “I’ve made
some great contacts, read many interesting studies and articles I wouldn’t
have known about otherwise, and I’ve
learned a great deal. It’s been the biggest
surprise of the decade for me.”
Dr. Aronson acknowledged the hesitancy many practitioners have about
L OUISE A RONSON
COURTESY OF
E
veryone has various identities, and
all physicians have other roles they
play. Louise Aronson, MD, MFA, is
very open about hers. On the front page
of her website, it states “Louise Aronson
is a doctor and a writer – or maybe a
writer and a doctor.”
Dr. Aronson, who will deliver the
Anne-Marie Filkin Lecture at AMDA’s
annual conference next month, urges
post-acute/long-term care practitioners
to tap into their inner writers, speakers,
and artists to express themselves, share
ideas, and start dialogues about health
and health care. In addition to being
the author of A History of the Present
Illness and numerous articles and papers,
Dr. Aronson also is associate professor of
medicine at the University of California
San Francisco.
“Some people are just straight up naturals, and some people have no creative
talent, but there are very few people in
either of those categories. The rest of
us are in the middle, meaning we have
some ability but have to work at it,”
Dr. Aronson told Caring for the Ages.
“How much you want it and how hard
you are willing to work at it is the difference. Most people aren’t Tolstoy, but
you can still be really good and effective.
You just have to be passionate and willing to do the work.”
when one publishes an article or book.
“For the most part, the feedback is very
positive and satisfying,” Dr. Aronson
said. “I get notes from people I don’t
know who say that my book was powerful to them. It is so gratifying to know
that it’s meant something to people, and
so astonishing that people are reading
what I write.” She admitted that, though
rare, negative feedback can be painful.
“I wrote an article for The New York
Times once, and I received some rather
scathing feedback from someone. The
person’s comments, it seemed to me,
distorted what I had to say and attacked
me personally in a way that was not very
nice,” Dr. Aronson said. “It was upsetting, but then I realized that it got even
more people talking about how we care
for our older adults, and that is a very
good thing.” Writers have to have a bit
of a thick skin, she noted, and they have
to resolve that they will learn and gain
something from feedback of all kinds.
P HOTO
B Y J O A N N E K A L DY
Louise Aronson, MD, MFA, said Twitter has transformed her medical career.
social networking, and she said she
can relate to their concerns. “It can be
overwhelming and tremendously time
consuming. But it presents an opportunity to learn so much more than
you normally would. Tapping into it
makes me a better physician and a more
informed person.” She also has made
life-changing contacts. “In Dublin, for
example, a geriatrician I met on Twitter
took me to places I never would have
seen on my own, including buildings
that were nondescript on the outside
but gorgeous inside, as well as a stunning, centuries-old library at the Royal
College of Physicians.”
The key to using social media wisely
is time management, Dr. Aronson said.
“Limit the amount of time every day you
spend on social sites. Set goals for your
activities, and determine what kinds of
connections you want to make.” She
suggested focusing on just one or two
sites, such as Twitter or Instagram. “Like
anything, it requires an initial investment of time. Eventually, you figure out
how to use and manage it. For example,
you can schedule tweets, then go about
your day and just look at responses when
you have a free minute,” she said. She
cautioned, “You just have to be careful
Plan Your
Conference
Experience
AMDA’s conference scheduler is now
available for registrants to customize,
save, print, and email their personal
2015 annual conference schedule.
Visit www.paltcmedicine.org/
custom-meeting-schedule/ to get
started.
not be become obsessed and check it
constantly.”
Writing a book or a journal article
might be a goal for some practitioners,
but others may want to start smaller.
Dr. Aronson suggested connecting
to local and regional groups – such as
AMDA state chapters – to learn about
opportunities to write or speak. “Look for
opportunities that fit with your skills and
interests. Keep your eyes open. For example, if there is an item in the news about
something that fits with your expertise,
use it to your advantage,” she said.
Do Something
Not everyone can or even wants to write,
Dr. Aronson acknowledged, but that
doesn’t mean these practitioners can’t
promote a dialogue. “You can circulate
ideas. If you read something you think is
interesting, share it – link to it on social
networking, mention it in a team meeting, or even build a grand rounds around
it,” she suggested. Another way to promote good ideas, she said, is to organize conferences that feature colleagues
whose writing or speaking you admire.
For those who want to write or speak,
Dr. Aronson said, “Know that it takes
work like anything else, but the more you
do it and the more positive feedback you
receive, the more you will enjoy it and
the more faith you will have in yourself.”
Dr. Aronson’s Filkin Lecture will
address “Adventures in Storytelling:
Telling Stories to Improve Post-Acute/
Long-Term Care.” Her presentation
will open the Closing General Session
at 8:30 a.m. on Sunday, March 22. C
fA
Senior contributing writer Joanne Kaldy
is a freelance writer in Harrisburg, PA, and
a communications consultant for AMDA
and other organizations.
CARING FOR THE AGES •
CARINGFORTHEAGES.COM
5
Benzodiazepine Use Increases With Age, Despite Risks
BY CAREY COWLES
P
rescription use of benzodiazepines
increases steadily with age, despite
the known risks for older people,
according to a comprehensive analysis of
benzodiazepine prescribing in the United
States. Given existing guidelines cautioning health providers about benzodiazepine use among older adults, findings
from a recent study raise questions
about why so many prescriptions – many
for long-term use – are being written for
this age group.
Mark Olfson, MD, MPH, at the New
York State Psychiatric Institute and
Columbia University; Marissa King,
PhD, at Yale University; and Michael
Schoenbaum, PhD, at NIMH used data
from the IMS LifeLink LRx Longitudinal
Prescription database and a national database on medical expenditures collected
by the Agency for Healthcare Research
and Quality to examine prescription patterns from 2008.
The researchers found that among
adults aged 18 to 80 years, about one in
20 received a benzodiazepine prescription in 2008, the period covered by the
study. But this fraction rose substantially
with age, from 2.6% among those aged
18 to 35 years, to 8.7% in those aged 65
to 80 years. Long-term use – a supply
of the medication for more than 120
days – also increased with age. Of people
aged 65 to 80 years who used benzodiazepines, 31.4% received prescriptions
for long-term use, vs. 14.7% of users
aged 18 to 35 years. In all age groups,
women were about twice as likely as
men to receive benzodiazepines. Among
women aged 65 to 80 years, 1 in 10 was
prescribed one of these medications,
with almost a third of those receiving
long-term prescriptions.
“These new data reveal worrisome
patterns in the prescribing of benzodiazepines for older adults, and women
in particular,” said Thomas Insel,
MD, director of the National Institute
of Mental Health (NIMH), which
supported the study. “This analysis
suggests that prescriptions for benzodiazepines in older Americans exceed
what research suggests is appropriate
and safe.”
In older people, research has shown
that benzodiazepines, prescribed to
treat anxiety and sleep problems, can
impair cognition, mobility, and driving
skills, and they increase the risk of falls.
Commonly prescribed benzodiazepines
include alprazolam (Xanax), diazepam
(Valium), and lorazepam (Ativan). The
study found that most prescriptions for
benzodiazepines are written by nonpsychiatrists. For adults 18 to 80 years
old, about two thirds of prescriptions for
long-term use are written by non-psychiatrists; for adults aged 65 to 80 years, the
figure is 9 out of 10.
The study appears online in JAMA
Psychiatry (JAMA Psychiatry 2014 Dec 17.
doi: 10:1001/jamapsychiatry.2014.1763.
[Epub ahead of print]).
CfA
®
makes all the difference
Aspiration Risks
from page 3
severity of the risks (think of the television ads listing possible drug side effects
starting with death). Your efforts to minimize those risks, such as therapeutic trials
or gradual introduction of the requested
regimen should be detailed. A change in
food consistency or the resident’s position
might be initiated at lunchtime, when
resident function and facility staffing is
likely to be greatest. Close observation,
close accessibility of suction equipment,
and other possible safety measures should
be explored and documented as should
the results of the first few trials. The decision should be revisited as two or three
episodes of severe choking might lead to
a different decision.
Our goal must remain to encourage
our residents to their highest attainable level of functioning, to the greatest
possible control over their own lives.
Mealtime is one of the few occasions
when residents can assert control. These
choices should be honored.
CfA
Dr. Nichols is president of the New York
Medical Directors Association and a member
of the Caring for the Ages Editorial
Advisory Board. Comment on this and other
columns at www.caringfortheages.com
under “Views.”
With CancerCare,
the difference comes from:
• Professional oncology social workers
• Free counseling
• Education and practical help
• Up-to-date information
• CancerCare for Kids®
For needs that go beyond medical care, refer your
patients and their loved ones to CancerCare.
CancerCare’s free services help people cope with
the emotional and practical concerns arising from
a cancer diagnosis and are integral to the standard
of care for all cancer patients, as recommended
by the Institute of Medicine.
Help and Hope
1-800-813-HOPE (4673)
www.cancercare.org
6 • CARING FOR THE AGES
FEBRUARY 2015
Some Providers Quicker to Tube Feed End-of-Life Elderly
B Y M I C H E L E G. S U L L I VA N
H
ospitalists who care for dementia
patients near the end of life are
much less likely to introduce a
feeding tube than other physicians who
follow such patients.
Compared with nonhospital generalists, hospitalists were 22% less likely to
tube-feed hospitalized nursing home
residents – and even less likely to tubefeed patients who were the most severely
impaired (35%). In contrast, subspecialists
were five times more likely to insert a
tube. When a mixed group of physicians
was on the case, rates were even higher,
with a 9-fold increase overall and a 9.5-fold
increase for severely demented patients.
The findings clearly illustrate that
nonhospitalists could benefit from some
education about the most appropriate
interventions when patients near the end
of life enter a hospital, Joan Teno, MD, and
her associates reported in Health Affairs
(Health Aff [Millwood] 2014;33:675-82).
“It may be that subspecialists do not
have adequate knowledge about the risks
and benefits of using feeding tubes in
people with advanced dementia,” said
Dr. Teno of Brown University, Providence,
RI, and her coauthors. “Hospitals should
educate physicians about the lack of efficacy of PEG [percutaneous endoscopic
gastrostomy] feeding tubes, compared
with hand feeding, in prolonging survival
and preventing aspiration pneumonias
PA/LTC Perspective
According to Ramona Rhodes, MD, MPH, division of geriatric medicine,
University of Texas Southwestern Medical Center, Dallas, TX, the long-term
care health care team should discuss options other than feeding tube placement
with family members. In declining patients with dementia, hand feeding may
be an alternative, albeit one with cost and staffing issues.
“Family members have reported that discussions with [health care] providers
about feeding tube insertion were either abbreviated or did not occur, and they
have sometimes felt pressured by the physician to insert a feeding tube,” she
said in an Annals of Long-Term Care “Ask the Expert” report. “They have also
noted that their loved one was often pharmacologically restrained, and they
were less likely to report excellent end-of-life care.”
Dr. Rhodes also noted the increased risk of infection in LTC residents with
feeding tubes who are transported to the hospital for care. “Health care providers in the LTC setting should be mindful of possible colonization of certain
bacteria and how to reduce spread of antimicrobial-resistant organisms in their
facilities. … Infection control programs may significantly reduce bacterial contamination associated with enteral feeding, and LTC providers should use this
information to create strategies that will reduce spread of antimicrobial resistance in their facilities.”
FDA Warns of Potentially Fatal
Skin Reaction With Ziprasidone
B Y A L I C I A A U LT
T
he Food and Drug Administration issued a warning that the
atypical antipsychotic ziprasidone
(Geodon) may be associated with a rare
but potentially fatal skin reaction.
The agency said it had reviewed six
worldwide cases of the condition, known
as drug reaction with eosinophilia
and systemic symptoms (DRESS), that
were associated with ziprasidone use.
All six cases were reported through the
FDA Adverse Event Reporting System.
Symptoms began within 11-30 days
after ziprasidone therapy was started.
In three cases, symptoms recurred – and
began more quickly – with discontinuation and reinitiation. There were no
deaths, but DRESS is potentially fatal,
with a mortality rate of up to 10%,
the FDA noted in a safety announcement. DRESS consists of at least three
of the following symptoms: cutaneous
reaction, eosinophilia, fever, and lymphadenopathy; and at least one systemic
complication, such as hepatitis, nephritis, pneumonitis, myocarditis, pericarditis, and pancreatitis.
The pathogenesis of the condition is
unclear, the agency said, but it added that
a combination of genetic and immunologic factors are thought to be at play.
The FDA said the six cases it reviewed
seem to be associated with ziprasidone
use because of the signs and symptoms,
the temporal relationship between initiation and onset of symptoms, and the
cases of positive rechallenge.
There is no specific treatment for
DRESS, said the agency, adding that early
recognition, quick discontinuation of the
offending agent, and supportive care are
all crucial to managing the condition.
The FDA said that patients should not
stop taking ziprasidone or change the
dose without talking with their physician, but noted that those who have a
fever with a rash and/or swollen lymph
glands should seek urgent medical care.
Clinicians should immediately stop
treatment if DRESS is suspected.
Adverse reactions involving ziprasidone should be reported to the FDA’s
MedWatch program.
CfA
Alicia Ault is a reporter with Frontline
Medical News.
and pressure ulcers in people with
advanced dementia. In addition, hospitals should examine how they staff the
role of attending physician and ensure
coordination of care when patient hand
offs are made between different types of
attending physicians.”
Such education would bring all physicians up to speed with position statements
against tube feeding for this group of
patients. The issue sits atop the Choosing
Wisely lists of both the American
Academy of Hospice and Palliative
Medicine and the American Geriatrics
Society. The American Academy of
Hospice and Palliative Medicine states
that “feeding tubes do not result in
improved survival, prevention of aspiration pneumonia, or improved healing
of pressure ulcers. Feeding tube use in
such patients has actually been associated
with pressure ulcer development, use of
physical and pharmacological restraints,
and patient distress about the tube itself.”
Internal medicine physician Eric G.
Tangalos, MD, CMD, of the Alzheimer’s
Disease Research Center at Mayo Clinic,
Rochester, MN, works closely with hospitalists. He agrees with the concept that
tube feeding can impose even more distress on both these patients and their
families. “As a medical profession and a
society, we have yet to accept some of
the futility of our actions and continue
to ignore the burdens tube feedings place
on patients, families, and the health care
system once a hospitalization has come
to its conclusion,” he said in an interview.
Dr. Teno and her team looked at
the rate of feeding tube insertion in
fee-for-service Medicare patients with
advanced dementia who were within
90 days of death and hospitalized with
a diagnosis of urinary tract infection,
sepsis, pneumonia, or dehydration. The
study examined decisions made by four
groups of physicians who cared for these
patients: hospitalists, nonhospitalist generalists (geriatricians, general practitioners, internists, and family physicians),
subspecialists, and mixed groups that
included a subspecialist and either a hospitalist or nonhospitalist generalist.
The cohort comprised 53,492 patients
hospitalized from 2001 to 2010. The
patients’ mean age was 85 years. About
60% had a do-not-resuscitate order, and
10% had an order against tube feeding.
The rate of hospitalists as attending physicians increased from 11% in 2001 to 28%
in 2010. The portion of patients seen by a
mixture of attending physicians increased
from 29% in 2001 to 38% in 2010.
The rates of tube feeding were lowest
when a hospitalist or nonhospitalist generalist was the attending physician (1.6%
and 2.2%, respectively). Subspecialists
had significantly higher rates (11%). The
highest rate occurred when there were
mixed groups of physicians involved in
the patient’s care (15.6%).
Using the nonhospitalist generalists as
a reference group, the researchers found
that hospitalists were 22% less likely to
insert a tube overall and 35% less likely
to do so when the patient had very severe
cognitive and physical impairment.
Conversely, subspecialists were five
times more likely to commence tube
feeding for all patients and for very
severely impaired patients. The mixed
groups were the most likely to begin
tube feeding – almost 9 times more
likely overall and 9.5 times more likely
for the most severely impaired patients.
“Our finding that subspecialists had a
higher rate of insertions of PEG feeding
tubes might reflect their lack of experience in providing care for people with
advanced dementia,” the authors wrote.
The mixed-physician group could be
seen as a proxy for discontinuity of care
among the attending physicians, they
noted. Prior studies have found that such
discontinuity was associated with longer
hospital stays.
“There may be a lack of care coordination during patient hand offs between
attending physicians that begins a cascade of events, ending with the insertion
of a PEG feeding tube,” they wrote.
Diane E. Meier, MD, professor of geriatrics and palliative medicine at Icahn
School of Medicine at Mount Sinai,
New York, and director of the Center
to Advance Palliative Care, agreed that
group care without a leader creates confusion. “One of the hallmarks of modern
medicine in the U.S. is fragmentation. It
is typical for a person with dementia
to have a different specialist for every
organ system, a problem compounded
in the hospital when a completely new
group of specialists is brought into the
care team. The problem with this abundance of doctors is that no one is really
in charge of the whole patient and what
makes the most sense for the patient as
a person. Organ- and specialty-specific
decision making leads to bad practices –
including trying to ‘solve’ a feeding difficulty as if it is an isolated problem
when the real issue is progressive brain
failure – a terminal illness that cannot be
fixed with a feeding tube.”
The study questions not only the feeding tube issue but also the wisdom of
repeatedly hospitalizing elderly patients
with severe dementia who could be in
the last phase of life – especially for
conditions that are expected complications of severe dementia. The authors
suggested that there may be financial
motives to admit fee-for-service patients.
“The fee-for-service system provides
incentives to hospitalize nursing home
residents with severe dementia because
such hospitalizations qualify the patients
for skilled nursing home services,” they
wrote. “Bundling of payments and institutional special needs plans that reverse
these financial incentives may reduce
health care expenditures and improve
the quality of care for nursing home residents with advanced dementia by avoiding burdensome transitions between
facilities and the stress of relocation.”
The National Institute on Aging
funded the study. Dr. Teno made no
financial declarations.
CfA
Michele G. Sullivan is with the MidAtlantic bureau of Frontline Medical
News.
CARING FOR THE AGES •
CARINGFORTHEAGES.COM
7
Dopamine Receptor Agonists Trigger Impulse Control Disorders
D
opamine receptor agonists are
suspected to have caused serious impulse control disorders in
at least 710 cases reported to the Food
and Drug Administration’s adverse drug
events database during a 10-year period.
The drugs, which are often prescribed
for Parkinson’s disease, restless legs syndrome, and hyperprolactinemia, were
implicated in more than 1,000 separate
adverse events that included pathological gambling, hypersexuality, compulsive
shopping, poriomania (wandering away
from home), binge eating, kleptomania, and compulsive sexual behavior.
Although this retrospective disproportionality analysis of information in a
public database could not prove causality, “the associations were significant, the
magnitude of the effects was large, and
the effects were seen for all 6 dopamine
agonist drugs” available in the United
States, reported Thomas J. Moore of the
Institute for Safe Medication Practices,
Alexandria, VA, and his associates
( JAMA Intern Med 2014;174:1930-3).
These findings confirm and extend
those of several previous reports in the
literature, but none of the dopamine
receptor agonists – pramipexole, ropinirole, cabergoline, bromocriptine, rotigotine, and apomorphine – currently carry
a boxed warning about the potential
for developing severe impulse control
disorders.
The researchers examined an FDA
database of all domestic and foreign
reports of serious drug events during 2003-2012. They focused on 1,580
reports of serious impulse control disorders and excluded cases involved in litigation or clinical studies. A total of 710
cases were related to dopamine receptor
agonists, of which 48% were reported
AMDA
from foreign countries, said Mr. Moore,
who is also with the department of
epidemiology and biostatistics, George
Washington University, Washington,
DC, and his colleagues.
The investigators calculated the proportional reporting ratio, “a ratio similar in concept to the relative risk ratio,”
between these cases and each individual
dopamine receptor agonist. They found
that the proportional reporting ratio
of each drug was high and statistically
Mary Ann Moon is a Frontline
Medical News freelance writer based in
Clarksburg, MD.
THE
SOCIETY
FOR
POST-ACUTE
– AND LONG-TERM CARE MEDICINE
MARCH 19-22
LOUISVILLE, KY
4XDOLW\
KENTUCKY INTERNATIONAL
CONVENTION CENTER
on7UDFN
IN LONG-TERM CARE
Calling all post-acute & long-term care
professionals…next month, don’t miss
the premier conference for YOU:
AMDA – The Society for Post-Acute and Long-Term
Care Medicine Annual Conference 2015
Warn Patients,
Then Monitor
Howard D. Weiss, MD, from Sinai
Hospital, Baltimore, and in the
department of neurology and neurological sciences at Johns Hopkins
University, Baltimore, and Gregory
M. Pontone, MD, from the department of psychiatry and behavioral
sciences at Johns Hopkins, wrote an
invited commentary accompanying
Mr. Moore’s report ( JAMA Intern
Med 2014;174:1935-7). Before prescribing dopamine receptor agonists,
physicians should warn patients and
their families or caregivers of these
drugs’ potential to “trigger uncontrollable gambling, sexual interests,
spending, or other behavioral addictions, and should regularly query
patients taking the drugs about conduct that could indicate development
of an impulse control disorder,” they
wrote.
But be aware that these disorders
often elude detection; some patients
will be intentionally deceptive or
will simply lack insight and will conceal abnormal behaviors from their
physicians and families. “A patient is
unlikely to spontaneously mention,
‘By the way, doctor, I lost $250,000 in
casinos last year,’ or ‘I purchase $500
worth of lottery tickets every week,’
or ‘I spend all night on Internet
pornography sites and solicit prostitutes,’ ” they wrote.
Dr. Weiss and Dr. Pontone
reported having no financial confl icts
of interest.
significant. In addition, the number of
case reports rose steadily over time,
from both within and outside the United
States.
“Our data, and data from prior studies, show the need for these prominent
[boxed] warnings” in the prescribing information for these drugs, they said.
CfA
2015
B Y M A RY A N N M O O N
Quality on Track in Long-Term Care
www.paltcmedicine.org
WHO: Health care professionals from across the
post-acute & long-term care continuum are invited to
attend, with focus on:
Q Administrators
QAttending physicians
QConsultant pharmacists
QDieticians
QHospitalists
QMedical Directors
QNurses
QPractitioners
QRehab Professionals
™
Continuing education credits will be available
for many disciplines.
Visit www.paltcmedicine.org/credit-statements/
for more information.
WHAT: The rich program is comprised of cuttingedge, evidence-based, unbiased education, including
nationally known general session speakers, intensive
workshops, a strong exhibit program, and many
networking opportunities.
WHEN: March 19-22, 2014
WHERE: Kentucky International Convention Center,
Louisville, KY
HOW: Register now at
www.paltcmedicine.org/register-now/
WHY: AMDA’s Annual Conference is the only
educational and informational forum of its kind in
the field of post-acute and long-term care. Providing
you with the tools and resources you need to apply
in the trenches, while networking with your peers,
colleagues, and top field experts.
8 • CARING FOR THE AGES
COPD
from page 1
This means having nursing home staff
well educated in the use of both inhalers and nebulizers, so they can “meet
residents where they are physically and
cognitively” to ensure that medication
is effectively delivered to the lungs, said
Limberg, who treats many frail elderly.
Pulmonary exercises are another main
piece of COPD care, as are empathy
and holistic attention to functional status and to the anxiety and depression
that often accompany COPD, she and
other sources said.
Although studies of COPD in nursing homes are hard to come by, the disease is such a major issue for post-acute
and long-term care, and there has been
such growth in the body of medical
literature, that AMDA is in the process
of revising its 2010 Clinical Practice
Guideline on COPD Management in the
Long-Term Care Setting. Publication of
the updated guideline is expected later
this year.
Challenges of Drug Delivery
Findings from a 2012 retrospective
analysis of more than 126,000 nursing
home residents suggest that bronchodilators – particularly the long-acting
forms referred to as controllers or maintenance medications – are underutilized in nursing homes. Of the 21.5%
of nursing home residents found in the
study to have a diagnosis of COPD, 17%
received no respiratory medications,
and approximately half received only
FEBRUARY 2015
monotherapy – usually nebulized therapy – with short-acting beta-agonists.
The study analyzed prescription
claims and minimum data set findings
from a 1-year period ending in 2010.
Exacerbations were defined as episodes
in which a patient received a short
course (< 14 days) of antibiotics or oral
corticosteroids or both ( J Manag Care
Pharm 2012;18:598-606).
Twenty-two percent of nursing home
residents with COPD experienced at
least two exacerbations of COPD during the 1-year study period, and as many
as 60% were not receiving a long-acting
agent. More than 55% were hospitalized
at least once, and 11% had at least one
emergency room visit.
Roy A. Pleasants, PharmD, of the
division of pulmonary, allergy, and critical care medicine at Duke University
School of Medicine, said the study’s
authors rightly surmised that the respiratory symptoms and exacerbations
experienced by nursing home residents
may have been related to the use of
short-acting beta-agonists in the absence
of long-acting beta-agonists or long-acting anticholinergic agents.
Nursing homes rely heavily on shortacting bronchodilators such as albuterol (a beta-agonist) and ipratropium
bromide (an anticholinergic), probably “because they work quickly and
they’re available by nebulization,” said
Dr. Pleasants, who has studied COPD in
nursing homes in North Carolina.
It’s unclear how much of this reliance
on short-acting and nebulized drugs is
due to the inability of many nursing
home residents to use metered-dose
Know the Symptoms
Much of the population with COPD – if not most – will be diagnosed before
nursing home admission. However, given that 50% of COPD in the general population is believed to be undiagnosed, nursing homes must be ready to consider
the disease in the face of multiple key indicators.
Pulmonary manifestations include dyspnea, chronic sputum production,
chronic cough, chest tightness, wheezing, and history of exposure to risk factors, such as tobacco smoke and occupational dusts and chemicals.
Less understood are the nonpulmonary indicators – most commonly, fatigue/
diminished energy, weakness, depression, and anxiety, said Gerard J. Criner, MD,
professor of medicine at the Temple University School of Medicine and director of the Temple Lung Center at the university’s hospital in Philadelphia. Such
nonpulmonary symptoms can be important clues, he said.
Spirometry is required for a definitive diagnosis, but because it is not widely
available at long-term care facilities and because the test is physically difficult
for many post-acute and long-term care patients, the diagnosis is sometimes
made provisionally at the bedside. The more manifestations, the greater the
likelihood of COPD.
However, facilities are increasingly buying spirometers or referring residents with suspected COPD to a pulmonologist for formal testing, said
Karl Steinberg, MD, CMD, editor in chief of Caring for the Ages. “More
facilities are getting spirometers these days as the prices have come down to
below $2,000. And some clinicians – if they suspect that a patient has undiagnosed COPD – will send the patient to a pulmonologist for formal testing as
opposed to just empirically starting meds for it,” he said.
In considering risk factors, it is important to note that although smoking is
the number one cause of COPD, approximately 25% people diagnosed with
COPD “have never smoked a cigarette in their life,” according to the COPD
Foundation website.
COPD has long been classified as mild, moderate, severe, or very severe – a
categorization that can be helpful in guiding treatment decisions – but the
method of categorization has recently changed. “The old GOLD guidelines
based the categories just on severity of airflow – spirometry results,” said
Dr. Criner. “The new guidelines take into account exacerbation history and
symptoms, mainly breathlessness. It’s a multidimensional approach now.” C
fA
—Christine Kilgore
inhalers or dry powder inhalers, and
how much is due to other factors. Cost
differences between nebulized and
inhaled drugs and a lack of awareness of
the availability of long-acting nebulized
drugs – such as arformoterol, a longacting beta-agonist, and budesonide, a
nebulized steroid – may also encourage short-acting drug use, he and other
sources said.
According to AMDA’s 2010 Clinical
Practice Guideline on COPD, studies
have shown that only 50% of individuals
are able to use metered-dose inhalers correctly and that this percentage decreases
in frail elderly patients and patients with
dementia. Still, according to the guideline, nebulizers are “significantly overused” in the LTC setting. Patients who
transfer from the hospital may initially
need a nebulizer but may not continue
to need it, the guidelines say.
Elderly who are strong enough to stand
up with assistance and take a deep inhalation on command – as well as patients
with milder forms of dementia – should
be able to use dry powder inhalers,
sources told Caring for the Ages. (In
the 2012 retrospective analysis of nursing home residents, nebulized therapy
was a common route of administration
regardless of residents’ level of cognitive
function.)
On the other hand, patients who are
not on nebulizer treatments may need to
be. Claudia Marcelo, DO, a nursing home
specialist for Life Care Physician Services
and CMD candidate, said she sees many
frail elderly patients who are released
from hospital stays for COPD exacerbations with prescriptions for inhaler treatments that they cannot use correctly.
“They come to the nursing home for
rehab, and they don’t have the medication on board that’s going to stop those
exacerbations from happening,” said
Dr. Marcelo, who is also the medical
director and full-time physician at Life
Care Center in Lauderhill, FL. “I automatically transition them to nebulizer
treatments because that is the only way
they are going to breathe in the medications they need.”
Unfortunately, the menu of available
COPD drugs is dominated by inhaler
medications, which generally are more
effective for COPD than drugs in the
nebulized form, Dr. Pleasants said. This
is unlikely to change anytime soon.
“There are once-a-day formulations
coming out that are pretty impactful
changes for COPD patients,” he said. “And
many believe that the ‘triple therapy’ combinations being developed – combinations
of a steroid with two bronchodilators –
will be game-changers. [These drugs] are
inhaler drugs, though, so they will have
some utility in the nursing home, but it
will be limited.”
Still, knowledge of all the options is key,
said Dr. Marcelo, who is helping to revise
AMDA’s clinical practice guidelines on
COPD. “There’s no cookie-cutter treatment plan for these elderly patients. …
Nursing homes need treatment protocols
for COPD, but [included in this is the
need for] an individualized approach.”
For maintenance, Dr. Marcelo most
commonly uses arformoterol and
budesonide, long-acting nebulized drugs
that Dr. Pleasants and other sources say
are underutilized in nursing homes. For
exacerbations, she adds albuterol and/or
ipratropium, and sometimes oral corticosteroids, depending on the patient’s
comorbidities and clinical state.
Preventing Exacerbations
How to best prevent exacerbations and
minimize the risk of hospital readmission are among the key questions being
pursued by the workgroup that is updating AMDA’s Clinical Practice Guidelines
for COPD.
Exacerbations account for most of the
morbidity, mortality, and costs associated with COPD, yet aside from the
general recommendations from GOLD
and other experts to optimize drug
therapies, ensure smoking cessation (see
Chasing the Smoke Away, pg. 10), prevent respiratory infections, and provide
pulmonary rehabilitation, there have
been few, if any, evidence-based recommendations that specifically address
exacerbation prevention.
‘There’s no cookiecutter treatment plan
for elderly patients. …
Nursing homes need
treatment protocols for
COPD, but [included
in this is the need
for] an individualized
approach.’
To fill the gaps, the American College
of Chest Physicians (CHEST) and
the Canadian Thoracic Society (CTS)
recently reviewed the evidence on prevention of acute exacerbations of COPD
and published a guideline. They reported
that “large gaps in knowledge” limited
their ability to prioritize one type of
therapy over another or to make strong
recommendations about combinations
of therapy for prevention.
Still, the new guideline presents a
variety of options. “Recommended”
pharmacological options for exacerbation prevention include long-acting
beta-agonists, inhaled corticosteroids,
and long-acting muscarinic antagonists.
“Suggested” pharmacological options
include long-term macrolides and phosphodiesterase inhibitors, such as rofl umilast and theophylline.
Recommended nonpharmacological therapies include annual infl uenza
vaccination, pulmonary rehabilitation
when it is provided within 4 weeks of
an exacerbation, and education and case
management, according to an executive
summary recently published online in
Chest.
Two-thirds of exacerbations are associated with respiratory tract infections
or air pollution, and one-third present
without an identifiable cause, the guideline notes. “Patients are 60%-70% more
See COPD • page 10
10 • CARING FOR THE AGES
FEBRUARY 2015
COPD
Corticosteroids have long been recommended for COPD patients who are
severely impaired and prone to exacerbation, and interest in the drugs may be
intensifying. A study published last year
in the Journal of the American Medical
Association garnered significant attention because it focused on seniors and
found that those who took combination therapy comprising long-acting
beta-agonists and inhaled corticosteroids had fewer hospitalizations and a
lower mortality than those who took
long-acting beta-agonists alone ( JAMA
2014;312:1114-21). The differences were
from page 8
likely to be hospitalized in a given year if
they were hospitalized the prior year for
a COPD exacerbation,” said Dr. Criner,
the lead author of the CHEST-CTS
guidelines and a member of the GOLD
board of directors. He said that pulmonologists should be involved in thoroughly
reviewing the care plans of nursing home
residents with severe COPD or recurring
exacerbations “to make sure all the bases
are covered.”
greatest among those with coexisting
asthma.
A Holistic Approach
Ideally, nursing homes would employ
respiratory therapists, Dr. Marcelo said,
but billing rules and economics currently
mean otherwise for a great majority of
homes. Dr. Marcelo fills the gap by teaching her nursing staff and therapists how
to help patients manage their shortness of
breath through basic pulmonary exercises.
Breathing techniques such as pursedlip breathing can help patients breathe
with less effort and conserve energy, for
Chasing the Smoke Away
© ISTOCKPHOTO . COM / TUNART
A
mid the uncertainties of best drug
treatments for chronic obstructive
pulmonary disease looms one important nonpharmacologic fact: Smoking cessation is the single most effective
way to improve outcomes for patients at
all stages of the disease.
It is the only measure that has been
definitively shown to reduce rates of
lung function decline. Clinical practice
guidelines from numerous organizations
are unequivocal on this point, and some
of them also point out that secondhand
smoke can exacerbate COPD.
What’s unclear is how this knowledge
is playing out in nursing homes, which
face dueling responsibilities of ensuring residents’ safety and respecting their
individual rights. It is not known how
many nursing homes have developed
smoke-free policies, but several sources
told Caring for the Ages that they
believe the numbers are at least slowly
ticking upward.
Smoking cessation “is the number one
treatment [for COPD],” said Claudia
Marcelo, DO, a nursing home specialist
for Life Care Physician Services. “Just as
hospitals have been going smoke-free, I
believe more nursing homes are starting
to go smoke-free. … The barriers should
be breaking down.”
Like the Life Care Center in Lauderhill,
FL, where Dr. Marcelo is the medical
director and a full-time physician, many
nursing homes are in a transition, prohibiting new residents from smoking,
but allowing existing residents to continue, she said.
Edgemoor DP SNF, a skilled nursing
facility in Santee, CA, run by the County
of San Diego, took smoking cessation a
step further. In 2009, it began its quest to
become smoke-free by reframing smoking as a privilege, rather than a right.
Residents interested in continuing to
smoke were required to have clinical
assessments to determine their ability to
handle all aspects of smoking. If deemed
capable of independent smoking, they
had to agree to a list of requirements for
smoking – a contract, of sorts. The residents were then monitored for compliance, and with any violation – dropping
a burning cigarette on the ground, for
instance, or giving a cigarette to another
resident – the smoking privilege was
lost. In the meantime, individuals being
admitted were told that the facility was
Many nursing homes prohibit new residents from smoking, but allow exising
residents to continue.
smoke-free and that they would not be
permitted to smoke.
The attrition resulting from these
changes was significant and brought
Edgemoor close to being smoke-free.
The facility faced one unforeseen obstacle, however: The edge of the facility
grounds became a de-facto smoking
area for several of the residents who
were permitted to leave the facility
unsupervised.
Littered cigarette butts and the smoking itself created neighborhood tension,
but leaders also worried about their
compliance with interpretive guidelines
for Medicare and Medicaid regulations,
as well as California regulations, which
mention the supervision of smoking.
“If there’s a de facto smoking area,
one could argue that we must supervise
it (for safety),” said Robert M. Gibson,
PhD, JD, senior clinical psychologist at
Edgemoor. “So we decided to further
develop our contraband policy to address
smoking materials and ensure that residents who were seen smoking were not
bringing back smoking materials.”
Repeated removal of contraband/
smoking materials further discouraged
even off-site smoking and smoking near
the facility.
Developing an effective smoke-free
policy can be complicated, but it is
wrong to assume that federal regulations prohibit nursing homes from going
smoke-free, according to the Tobacco
Control Legal Consortium. Medicare
and Medicaid regulations do not specifically mention smoking in regard to
resident choice, and although an interpretive guideline mentions the need to
accommodate existing smokers, it cannot be read to confer a right to those
who cannot smoke independently, or to
confer the right to smoke indoors, the
Consortium says.
“You have to be deliberate and clinical, and careful that you’re not taking
away something from someone who
already had it unless you have a reason,”
said Rebecca Ferrini, MD, CMD, fulltime medical director at Edgemoor. For
Dr. Ferrini and her colleagues, smoking
was not only a fire hazard; it entailed
“using staff time to promote a dangerous behavior,” they said.
As smoking rates declined, Dr. Ferrini
said, staff observed fewer behavioral
problems, particularly among those
with dementia, fewer respiratory infections, and improved wound healing.
“We haven’t documented it specifically, but these changes [have definitely
occurred],” she said.
And surprisingly, she said, there was
little need for nicotine replacement or
other smoking cessation tools. “For
the majority, we found that not having
smoking visible and not having ‘smoking times’ was enough. It was no longer
a social thing, and many just forgot.” C
fA
—Christine Kilgore
instance, and devices, such as the Acapella
(Smiths Medical, Dublin, OH), can help
improve clearance of secretions and build
strength for inhalation, she said.
“The frail elderly are so weak, and
their lungs get so stiff that they automatically start taking shallow breaths. They
become easily hypoxemic, and before
you know it, there’s such an accumulation of sputum that they become very
susceptible to pneumonia and aspiration,” she said. “We need to do better in
providing appropriate exercises.”
Monitoring patients for hypoxemia
and maintaining functional ability,
despite dyspnea, are both critical for residents with COPD, said Albert A. Rizzo,
MD, chief of Christiana Care Health
System’s Pulmonary and Critical Care
Medicine Section in Wilmington, DE.
“Becoming even more sedentary makes
one feel even more short of breath,”
he said. “It doesn’t worsen the lung
condition – it’s just that the lungs are
performing in a less conditioned body.”
Caregivers must also be attentive to possible depression and anxiety, and treat them
accordingly, Dr. Rizzo and Dr. Marcelo
both emphasized. (In the 2012 study of
COPD in nursing homes, 50% of those
with COPD also had diagnosed depression,
and 23% had anxiety.) Compassionately
educating residents and their families
about what to expect with COPD can
also lessen anxiety and fear, they said.
Empathy and emotional support
become all the more important in the
later stages of disease, when “patients
have such severe obstruction they
can’t take a deep breath, and they can’t
move enough air to meet their body’s
needs,” said Limberg, who also is serving on AMDA’s guideline revision panel.
“There’s no break from the [intense]
work of breathing and anxiety – every
breath taken needs to be followed by
another breath,” she said.
Palliative interventions,
such as morphine, are
appropriate for use in
patients at advanced
stages of COPD.
Palliative interventions, therefore, are
often crucial for advanced COPD. The
use of morphine at advanced stages,
when dyspnea is severe, despite optimization of drug therapy and implementation of nonpharmacologic interventions,
is an appropriate next step, sources said.
The AMDA Clinical Practice Guidelines
on COPD encourage practitioners to be
proactive about the use of opioids, and
the upcoming revision will no doubt
convey the same message.
“Morphine is absolutely OK,”
Dr. Marcelo said. “In fact, it’s underutilized in the frail elderly with advanced
COPD. Respiratory depression is not the
worst thing that can happen. … Patients
are in so much distress and discomfort,
and they finally have some relief with
shallow but comfortable breathing.” C
fA
Christine Kilgore is a freelance writer
based in Falls Church, VA.
CARING FOR THE AGES •
CARINGFORTHEAGES.COM
11
Journal Highlights
From the February
Issue of JAMDA
Exercise With Vibration
Exercise on a vibrating platform,
originally believed to provide greater
improvements in body balance, muscle
performance, and fall prevention, in
reality provides no greater benefits than
exercise on a stationary surface, according to a multicenter randomized parallel
assessor-blinded clinical trial in Spain.
Led by Mercè Sitjà-Rabert, PhD, of
Blanquerna School of Health Sciences in
Barcelona, researchers randomized 159
nursing home residents in the Barcelona
metropolitan area to perform balance
and strength training exercises either
alone or on a vibrating platform, an
exercise known as whole body vibration
(WBV) training. Individuals participated
in three 30-minute sessions a week for
6 weeks, with measurements taken at
baseline, 6 weeks and 6 months.
“Understanding the current social context in Spain is crucial to understanding
our motivations in this study,” Dr. SitjàRabert told Caring for the Ages. “The
senior citizen community is growing.
Because of this, there are an increasing number of nursing home residents.
Unfortunately, this group experiences
difficulties in daily living activities and
are at higher risk of falling than seniors
who don’t live in institutions.”
The researchers expected exercise
with WBV to provide greater improvements in balance and lower limb
strength than exercise alone, Dr. SitjàRabert said. However, both groups
showed significant improvement at 6
weeks and 6 months, with no significant differences between the groups in
balance, gait and functional mobility, or
muscle performance. Maximum speed
for the sit-to-stand muscle performance
test actually worsened by 5% among the
individuals who received whole body
vibration training, yet improved by 10%
among those who performed the exercises alone.
Although the researchers also expected
fewer falls in the group that received
WBV training, they found no differences
between the two groups. Also, none of
the 57 falls that occurred during the 6
months of the study were directly associated with the study.
The researchers observed no severe
adverse effects from WBV, and no differences in the occurrence of adverse
events between the groups. Pain, mostly
localized to the knees and lumbar spine,
was the most common event, followed
by muscle soreness. In some instances,
individuals developed itching, erythema,
and edema of the legs, although these
usually disappeared by the third or
fourth week of the study.
“Our study confirmed WBV training is equivalent in efficacy to exercise
without vibration,” Dr. Sitjà-Rabert
said. “However, the duration of our
study wasn’t long enough to determine
the efficacy of WBV to prevent falls
in institutionalized older people. More
investigation is needed to find out if
these exercises are appropriate in nursing homes.”
Also, longer studies that involve larger
samples are needed to assess falls, the
researchers said.
▶ Source: Effects of a Whole Body
Vibration (WBV) Exercise Intervention
for Institutionalized Older People: A
Randomized, Multicentre, Parallel Clinical
Trial – Sitjà-Rabert M, et al.
Sit-To-Stand Activity, Mobility
Sit-to-stand activity shows promise as a
way to optimize mobility and function
for nursing home residents who have
dementia, according to a longitudinal
quasi-experimental study in Edmonton,
Canada.
Led by Susan E. Slaughter, PhD, of
the University of Alberta in Edmonton,
researchers for the Mobility of
Vulnerable Elders study had health care
aides from four nursing homes prompt
56 residents with dementia to repeat a
sit-to-stand activity, which consisted of
repeatedly standing up from a seated
position and sitting down in a controlled
manner, four times daily during normal
care routines. Fifty-five residents with
dementia from three additional nursing
homes served as controls.
Over 6 months, residents who completed the sit-to-stand activity demonstrated less decline in mobility and
functional outcomes, as measured
by the 30-second sit-to-stand test and
Functional Independence Measure,
respectively, the researchers found. Also,
the Quality of Life-Alzheimer’s disease
measure showed health-related quality of life increased in the intervention
group and declined in the control group.
“The Mobility of Vulnerable Elders
study is one of the first to demonstrate
that a simple mobility intervention,
integrated into the daily care routines
of health care aides, can help slow the
decline in mobility and function in activities of daily living of nursing home
residents with dementia,” the researchers said.
Future research should focus on
assessing sustainability of these benefits,
they added.
▶ Source: Mobility of Vulnerable Elders
Study: Effect of the Sit-to-Stand Activity on
Mobility, Function, and Quality of Life –
Slaughter SE, et al.
CfA
Jeffrey S. Eisenberg, a freelance writer
in the Philadelphia area, compiled this
report.
The American Medical Directors
Certification Program is now the
American Board of Post-Acute and
Long-Term Care Medicine.
The name change reflects 2014 changes to the
ABPLM’s mission, and recognizes the increasing
prominence of post-acute care in the long-term care
continuum. The ABPLM mission statement is “to
recognize and advance physician leadership and
excellence in medical direction and medical care
throughout the post-acute and long-term care
continuum via certification, thereby enhancing quality
of care”.
Certified Medical Director
(CMD)* Application Deadlines:
April 1, 2015 and
October 1, 2015
Download application online at:
http://www.amda.com/certification/process.cfm
*The ABPLM will continue to administer the Certified Medical
Directors (CMD) Program. Current CMD certification and
recertification requirements remain the same and are unaffected
by the name change.
American Board of Post-Acute and Long-Term Care Medicine
11000 Broken Land Parkway, Suite 400
Columbia, MD 21044
[email protected]
Phone: 410-992-3117
Fax: 888-249-6533
12 • CARING FOR THE AGES
FEBRUARY 2015
Public
Policy
Dear Dr.
Jeff
By Charles Crecelius, MD, PhD, CMD, FACP
ACOs Turn Up the Heat Among Skilled Nursing Facilities
A
ccountable care organizations are
increasingly entering the postacute market. It is estimated that
about 10% of Medicare recipients currently receive their health care through
an ACO, and this number is expected to
rise. Post-acute care makes up just over
15% of the average cost per Medicare
recipient every year, with skilled nursing being the leading form of service.
ACOs are charged with reducing cost
while maintaining quality, so it is natural
that they are starting to scrutinize ways
to improve skilled nursing facility care
utilization and performance.
The Concerns
The current prospective payment system
(PPS) pays a per diem rate that heavily
favors therapy services, which many feel
provides little incentive to reduce lengths
of stay. Individuals must spend 3 nights
as a fully admitted hospital patient to
qualify for SNF benefits (the so-called
“3-day rule”) under Medicare Part A.
Additionally, they have a right to select
any SNF that can meet their needs. ACOs
would ideally like to refer their patients
to SNFs that can treat all manners of
medical needs in a timely, cost-effective
fashion. The ideal way for an ACO to do
this would be to allow them to bypass the
3-day rule, and to allow them to guide
patients to select SNFs that provide the
best care. The Centers for Medicare &
Medicaid Services has been listening to
these issues, and on Dec. 1, 2014, CMS
proposed a rule to answer these concerns. These proposals are not final and
are subject to a comment period, but it is
anticipated they will only be refined and
left largely unchanged.
3-Day Rule Revisions
The 3-day rule has been a contentious
issue for nearly all providers for years.
CMS has contended it is necessary to
prevent overuse of expensive SNF services. Since ACOs are responsible for all
costs, this argument is less applicable. In
fact, Medicare Advantage plans, which
have similar responsibility for total considerations, have been exempted from
the 3-day rule for years. Some Pioneer
ACOs, which have more flexibility since
they came out of the CMS Innovation
Center, started tailored waivers for the
3-day rule in April 2014, but this did not
apply to the CMS-run Medicare Shared
Savings Program (MSSP) ACOs. The
proposed rule now explains under what
circumstances MSSP ACOs can waive
the 3-day rule.
CMS does not believe a waiver should
result in SNF overutilization at the
expense of an appropriate acute hospital
stay. The patient must be medically stable, have certain defined diagnoses, not
require extensive testing and evaluation,
and need SNF services and rehabilitation. The greatest utility and savings
would result when the entire hospital
stay (and expense) is avoided and the
patient is directly admitted to the SNF,
such as from a physician’s office or emergency department. The SNF would have
to demonstrate it has adequate staff,
capacity, and infrastructure to care for
such patients. SNFs would be expected
to have a minimum Three-Star rating
and be required to be either an ACO participant or a provider/supplier in order
to align incentives.
The ACO would be required to meet
various transparency requirements,
including indication of their intent to
use such waivers on their application
and renewals, and submission of a written plan detailing how the waiver would
meet the needs of the assigned beneficiaries. The governing body would have
to make a bona fide determination of
the waiver need, and post the use of
such waivers as part of public reporting.
The ACO must remain in compliance
with the MSSP program. CMS would
reserve the right to audit and monitor
for possible abuse of the waiver (e.g.,
premature discharge to the SNF) and
terminate the waiver if abuse was determined. Marketing services also would
be monitored for potential misleading
information or coercion.
Perhaps most importantly, CMS has
proposed to limit this waiver to only
those MSSP ACOs that are Track 3 programs. Track 3 programs have “twosided risk,” and incur financial penalties
if spending goals are not met. Most
MSSP ACOs have been operating on
“one-sided risk” – they can share in savings to the program, but do not incur
any penalty if they do not save or cost
the program more. Many MSSP ACOs
are still not ready to transition to twosided risk, where CMS believes maximal incentives occur. Using a 3-day rule
waiver as an incentive to two-sided risk
serves CMS’s goals well.
ACO Selection of SNFs
Currently, hospitals are required to provide patients a list of SNFs in their geographic area. They must also disclose
any hospital relationship to the SNF, and
must not direct patients to a specific provider. Physicians, and at times case managers, give patients information about
homes they perceive are better, but this
informal direction is not officially recognized, and often does not work to the
advantage of the ACO.
ACOs would like to utilize highquality SNFs that can shorten lengths
of stay and, more importantly, reduce
rehospitalizations in order to meet goals
of lowering costs and providing quality.
Those SNFs with an established track
record of providing such care could
benefit tremendously, and those with
poorer performance could soon have
empty skilled units.
CMS has proposed a narrow waiver
for Track 3 MSSP ACOs only. Hospitals
that are ACO participants or ACO providers/suppliers still would be required
to provide a complete list of all SNFs
and respect patient choice, but they
would be allowed to make recommendations of preferred SNFs they have a
relationship with that provide better
continuity of care. Discharge planners
would be required to document the data
and the rationale they used as the basis
for recommending any specific provider
of post-hospital services.
SNFs and ACOs would have to meet
the criteria listed above for the 3-day rule
waiver, such as Three-Star rating and
transparency requirement. Generally,
CMS is supportive of hospitals recommending certain post-hospital providers based on quality and a beneficiary’s
specific needs, as long as the beneficiaries understand their other options and
retain their freedom of choice.
Risks and Waivers
There are many issues and concerns
with the proposed changes. If ACOs
can suddenly admit patients to the SNF
from the emergency department or
observation status, will there be enough
SNF beds – much less high-quality SNF
beds – to meet the demand? This could
be a welcome opportunity for the better
performing SNF, but a difficult time for
the ACO trying to find the right home
at the right time for each patient. CMS
has questioned if the SNF should have
to be an ACO provider, which might
provide some relief to the access to care
problem. Ultimately, if the ACO bears
two-sided risk, does it make a difference
if the SNF is an ACO provider?
A significant concern is what parameters hospitals should use to formulate
their lists of post-acute providers and
what information would be shared
with beneficiaries. Should hospitals
share only information on quality that
is publicly reported, such as on Nursing
Home Compare, or is it appropriate for
hospitals to also share information that
they have generated internally? There
would be real concerns if hospitals
steered beneficiaries to providers based
on quality information that has not been
properly vetted. There should also be
concerns if hospitals recommend only
their partnering providers when there
may be other providers of equal or better quality. CMS is planning to report
30-day rehospitalization rates as part of
Nursing Home Compare, and this is
obviously a metric that will be of interest to ACOs.
Another concern is whether these
waivers are at odds with CMS’ decision
in this proposed rule to continue to make
the SNF a primary care site. If waivers
place patients who were previously cared
for in the hospital into the SNF instead,
and the SNF is viewed as a care continuity
site from the hospital, is the SNF really a
primary care site, or is it, instead, a hospital substitute? AMDA has contended that
the SNF site should not be a primary care
site for the purposes of physician value
modifier comparison groups, as the per
day cost basis is much higher than in the
office setting, leading to unfair penalties
to the physician caring for SNF patients
under value-based medicine. If the ACO
is responsible for all costs at all sites of
service and these waivers go into effect,
CMS’s rationale for inclusion of SNFs as
a primary care site for other value-based
programs makes little sense.
Given the proposed waivers, would
the current ACO quality measures,
such as the new Skilled Nursing Facility
30-Day All-Cause Readmission Measure
and other measures used by ACOs, be
sufficient to help protect against inappropriate care or withheld care?
The ACO proposed rule may bring
new solutions to old problems, but it
also brings with it new issues. AMDA
and other stakeholders are reading it
very carefully and deliberating comments that they will develop. AMDA is
interested in hearing from you if you currently participate or plan to participate
in an ACO. If you would like to share
your experiences, please contact AMDA
at [email protected]. Ultimately,
we are being given an opportunity to
improve the health care system. May
we and others, including CMS, have the
wisdom to build it right.
CfA
Dr. Crecelius is a private practitioner,
multifacility medical director for Delmar
Gardens Nursing Homes in St. Louis, and
assistant clinical professor of internal
medicine and geriatrics at Washington
University School of Medicine. Currently
chair of AMDA’s Public Policy Committee
and alternate advisor to the AMA RVS
Update Committee, he is a past president of
the association. You can comment on this and
other columns at www.caringfortheages.com,
under “Views.”
CARING FOR THE AGES •
CARINGFORTHEAGES.COM
13
NSAIDs Linked to Bleeding, Thromboembolism in AF Patients
BY AMY KARON
T
aking nonsteroidal anti-inflammatory drugs for 14 days more
than doubled the risk of serious
bleeding in patients with atrial fibrillation, and it increased the risk of thromboembolism by 36%, according to a
report published in Annals of Internal
Medicine.
Risk of serious bleeding and thromboembolism with NSAID therapy rose
even further when patients with AF also
took oral anticoagulants, said Morten
Lamberts, MD, PhD, of Gentofte
University Hospital in Hellerup,
Denmark, and his associates.
Physicians should be careful about prescribing any type of NSAID to patients
with AF who are on antithrombotic
therapy, the authors said, and “should
choose safer alternative analgesic agents
when possible.”
Antithrombotics are key to treating
AF, but they increase bleeding risk. To
understand if NSAID exposure further heightened that risk, the investigators analyzed national registry data
on 150,900 patients hospitalized with a
first-time diagnosis of AF between 1997
and 2011. The age range was 65-83 years,
median age 75 years. Forty-seven percent
of the patients were women. Almost
70% were taking antiplatelet therapy,
oral anticoagulation therapy, or both at
baseline, and 5% were also taking an
NSAID, the researchers reported (Ann
Intern Med 2014;161:690-8). During a
median follow-up of 6.2 years, 35.6% of
patients were prescribed NSAIDs at least
once, 11.4% had serious bleeding events,
and 13% had thromboembolic events,
the investigators said.
Just 14 days of NSAID exposure more
than doubled the risk of serious bleeding (HR, 2.27; 95% CI, 2.15-2.40), and
increased the risk of thromboembolism
by more than a third (HR, 1.36; 95% CI,
1.27-1.45), they reported.
Notably, concomitant oral anticoagulant treatment almost tripled the risk of
serious bleeding (HR, 2.96; 95% CI, 2.643.31), and it also increased thromboembolism risk (HR, 1.67; 95% CI, 1.41-1.98),
the investigators said.
In terms of absolute risk difference,
taking NSAIDs led to 1.9 more serious
bleeding events per 1,000 patients who
took NSAIDs, compared with patients
who did not take NSAIDs, and risk
difference rose to 2.5 events per 1,000
when patients were also prescribed
oral anticoagulants. “This suggests a
serious bleeding event in one of 400500 patients exposed to an NSAID for
14 days,” they said.
Therapy with NSAIDs heightened
the risk of serious bleeding and thromboembolism regardless of patient antithrombotic regimens, but diclofenac and
naproxen were linked to the greatest
increase in bleeding risk.
“Our data support previous recommendations that NSAIDs should be discouraged unless other possibilities (such
as physical therapy, acetaminophen,
or alternative analgesics) have been
exhausted,” the researchers wrote. “This
highlights the double-edged nature of
NSAIDs in patients with AF: They not
only increase the risk for bleeding but
also predispose patients to thromboembolism and seem to cancel the protective effect of [oral anticoagulants] on
thromboembolism.”
The registries did not include data
on international normalized ratios, and
the researchers did not assess potential
confounders such as smoking, body
mass index, and left ventricular ejection
fraction. In addition, the study included
only AF patients discharged from the
hospital, among whom there may be a
greater susceptibility to bleeding than
in AF patients seen only in primary care
settings, the researchers wrote.
Two of the 12 coauthors reported
relevant financial relationships with
Astellas, AstraZeneca, Bayer, Boehringer
Ingelheim, Biotronik, BMS/Pfizer,
Cardiome, Daiichi, Merck, Portola,
and Sanofi. One coauthor reported
serving on speakers bureaus for Bayer,
BMS/Pfizer, Boehringer Ingelheim,
and Sanofi-Aventis. Another coauthor reported receiving grant support
from the Capital Region of Denmark
Foundation for Health Research. The
other investigators declared no financial
disclosures.
CfA
Amy Karon is a Frontline Medical News
freelance writer based in Albuquerque, NM.
2015 Educational Programs
2015 Individual & Bundled Webinars –
Live & On-Demand:
9 webinars will be offered this year on topics including: Infection Control,
Resident Rights, Cultural Diversity, CMS 5-Star System, Cardiology Issues,
Pitfalls of EMRs, Hospice, The Role of the Physician in Person-Centered Care,
& Medical Necessity. Purchase the bundle for an additional discount. NEW
discounts for AMDA members.
www.amda.com/cmedirect/#web
Core Curriculum on Medical Direction
in Long-Term Care: Part I Online
Dates:
January 5 – March 2, 2015
April 6 – June 1, 2015
www.amda.com/cmedirect/core-part-1.cfm
Core Curriculum on Medical Direction
in Long-Term Care: Live Program
Dates:
July 18-24, 2015
Location: Baltimore, MD
Fall 2015: TBD
www.amda.com/education/core/index.cfm
Advanced Curriculum on Medical
Direction in Long-Term Care
Date:
October 2-4, 2015
Location: St. Louis, MO
www.amda.com/education/advanced/index.cfm
™
14 • CARING FOR THE AGES
FEBRUARY 2015
Meditations on Geriatric Medicine
By Jerald Winakur, MD, MACP, CMD
Defining the Geriatrician’s Role in ‘Assisted Dying’
D
iane Rehm, who hosts a popular
WAMU radio talk show based at
American University in Washington D.C., recently lost her husband,
John, to end-stage Parkinson’s disease.
“We called in the doctor and John said to
him, ‘I am ready today’ and asked him for
assistance in dying,” Ms. Rehm said in an
interview with Maggie Fox of NBC News.
John and Diane were “surprised and
disappointed” when their doctor said,
“I cannot do that legally, morally, or
ethically. I don’t disagree with your wish
that you could die with the help of a
physician, but I cannot do it in the state
of Maryland.” The Rehms, in Diane’s
words, felt betrayed.
My problem with how the doctor
framed his dilemma is this: If he refused to
participate in Mr. Rehm’s death on moral
or ethical grounds, does it really matter that he was practicing in Maryland?
Suppose this case had presented in
Oregon? Then what would he have done?
Thus, John Rehm chose to deliberately die by dehydration. It took 9 days.
His doctor did not walk away. According
to the interview, the “doctor kept an
eye on him, administering low doses of
morphine to control the discomfort.”
“He did not seem to feel pain,”
Ms. Rehm said. Was this a “good” death
or a bad one? Apparently, Ms. Rehm felt
that her husband’s death should have
been handled differently.
Having lived through this experience,
and now super-charged by the Brittany
Maynard story (the young California
woman with a glioblastoma who moved
to Oregon to avail herself of this state’s
laws regarding physician-assisted suicide
[PAS]), Ms. Rehm, and the media in general, have elevated the right-to-die movement into the public consciousness.
Time for a Conversation
End-of-life controversies stymie, frustrate,
sadden, and enrage Americans, especially
now that the boomer cohort continues to
swell the ranks of our nation’s elderly –
soon to be 20% of the population. We are
tremendously confl icted about the decisions that we and our loved ones must
make in these circumstances. Although
polls taken by organizations such as
Compassion and Choices show that 65%
of us support an option “to help people
choose a quicker, more painless death,”
at least as many of us still don’t have an
advance directive or a designated surrogate decision maker, the basic building
blocks of autonomy at end of life.
Currently, PAS is legal in Oregon,
Washington, Montana, Vermont, and
New Mexico. Even in these states,
restrictions apply. In Oregon, one must
be legally competent, terminally ill
(with fewer than 6 months to live) as
determined by two physicians, endure a
2-week waiting period, and have the ability to self-administer a lethal dose of oral
medications. It is noteworthy that about a
third of patients never fill the prescription;
that they have control of their fate is reassurance enough. And, undoubtedly, dying
patients are deserving of as much support
and reassurance as we can give them.
In an interview on Ms. Rehm’s radio
show on Oct. 23, 2014, Ira Byock, MD,
a well-respected palliative care medicine
physician, stated:
“Oregon’s law was modeled after
Holland and Belgium. And in Holland
and Belgium these days, people are
being euthanized, by their own volition,
for things like depression or ringing of
the ears, not just pain.
“What’s happening now is that over
85% of people who use Oregon’s law
and end their life do so because of existential or emotional suffering, feeling of
being a burden to their families, feeling
the loss of the ability to enjoy life, feeling the loss of meaning.
“Well, once those become criteria,
there are a lot of problems, and human
suffering then becomes open to assisted
suicide and euthanasia. It’s an undeniable fact that the slippery slope exists.
“One of the things I disagree with is
that Brittany Maynard [had] just said
again that she thinks it’s her personal
choice. But you know, physician-assisted
suicide is not a personal act, it’s a social
act. Physicians aren’t personal. We are
trained by society … . So when a physician writes a lethal prescription, it’s a
social act.”
The PAS movement – adherents
of which prefer the less emotionally charged term “physician-assisted
dying” – is growing and deserves the
support of those among us who believe
Panel
Discussion
An engaged panel of PA/LTC
thought leaders will discuss PA/LTC
quality from multiple perspectives
on Sunday, March 22, at the AMDA
annual conference in Louisville, KY.
The panel will discuss issues in health
policy, information technology, quality improvement organization, and
clinical practice. This final-day panel
discussion is new for 2015 and promises to help health care professionals
prepare for the future of PA/LTC.
For more information, visit
http://www.paltcmedicine.org/.
that it is the role of doctors to assist
patients to suicide. Many in this movement believe that Dr. Byock’s attitudes
are too steeped in religious ideology and
old school medical paternalism.
“We do not let our little animals suffer and people shouldn’t have to suffer,”
Ms. Rehm stated in her NBC interview.
With all due respect to Peter Singer and
the folks at PETA (People for the Ethical
Treatment of Animals): People aren’t
pets, and physicians – specifically geriatricians – aren’t veterinarians. To make such
a comparison is overly simplistic and runs
counter to centuries of medical tradition
and practice, not to mention religious
and secular philosophical teachings.
Sliding Down the Slippery Slope
In these austere times of impending
Medicare insolvency, when “accountable
care” legislation puts increasing pressure on doctors to save money at every
turn – especially in the treatment of the
oldest and frailest among us – the slope
from PAS to euthanasia is a slippery
one. We live in an increasingly ageist
culture. It is up to us, frontline caregivers, to constantly monitor and speak out
about health care trends that endanger
those patients to whom our professional
careers have been dedicated.
The PAS movement ...
is growing and deserves
the support of those
among us who believe
that it is the role of
doctors to assist patients
to suicide.
That said, no patient with a terminal illness ought to suffer at life’s end.
Almost all patients can be made comfortable in their final days with modern
palliative medicine approaches, although
they are not always readily obtainable.
But just because excellent palliative and
end-of-life care is not readily available for
some, is this a reason to embrace physician-assisted dying? Or should this be a
societal imperative to provide the medical, educational, and social resources to
train doctors and their teams in humane,
compassionate, technically superlative
care at life’s end?
Yes, John Rehm had to deprive himself
of food and water in order to end his life,
advice often given to hospice patients
as they succumb to a host of end-stage
diseases. But, according to his wife, he
was not in pain. Was his end of life care
a betrayal on the part of his physician,
or not?
Who Makes the Call?
No matter if society calls it physicianassisted suicide or physician-assisted
dying, the essential issue for those of us
who are trained, dedicated, and committed to caring for the most vulnerable
among us is identifying our moral and
ethical concerns.
Is there a difference between writing
a prescription for a lethal dose of barbiturates for a young, obviously competent patient like Brittany Maynard with
a clear-cut, devastating terminal illness,
and for someone like John Rehm – nursing home-bound and locked-in by his
Parkinson’s disease? Or someone like
him who may now – or soon – be unable
to self-administer his medications? Or
someone whose capacity to make autonomous decisions may vary from day to
day, even hour to hour?
Who, then, decides the time to somehow administer the lethal medication
into the patient? Is it the role of the physician to continue to assist? Or perhaps
the dutiful wife will manage to get the
pills down somehow. Is this still assisted
suicide or “aid in dying?” Or has some
line been crossed?
Do we abandon trying to parse the
difference between physician-assisted
dying and euthanasia? In addition to all
the natural – not to mention the iatrogenic – end-of-life suffering we will allegedly alleviate, society will save trillions
of dollars as the boomers age. This, in
turn, will alleviate the burden on the
Gen Xers and Millennials. The wonks
who invented “QALYs” (quality-adjusted
life years) will be triumphant.
Perhaps the answer is to leave the physician out of the equation altogether;
after all, one doesn’t need a medical
degree to log onto the Hemlock Society
website. Doctors’ professional ethics are
now suspect when weighed against the
self-empowerment movement of our
current American zeitgeist.
Ponder this, my fellow health care
providers, because soon you may well
be asked to assist.
CfA
Dr. Winakur is a clinical professor of
medicine and associate faculty member at the
Center for Medical Humanities and Ethics
at the University of Texas Health Science
Center at San Antonio. The author of the
book “Memory Lessons: A Doctor’s Story,”
Dr. Winakur lectures across the nation on
ethical care giving in aging America. You
can comment on this and other columns at
www.caringfortheages.com, under “Views.”
CARING FOR THE AGES •
CARINGFORTHEAGES.COM
15
The White House Conference on Aging: 20 Years Ago
B Y J O A N N E K A L DY
T
he White House Conference on
Aging has a long and rich history
of addressing aging-related issues.
Since the first conference in 1961, these
conferences have generated ideas that
have gained traction and resulted in key
improvements to Medicare, Medicaid,
and other programs. Additionally, the
programs have brought national attention to issues such as end-of-life care and
advance directives. AMDA – The Society for Post-Acute and Long-Term Care
Medicine has been significantly involved
with conference policymaking since
1995, helping to bring the WHCOA into
the national spotlight.
AMDA members Eric Tangalos, MD,
CMD, professor of medicine at the Mayo
Clinic, and Kerry Cranmer, MD, CMD,
were delegates at the 1995 WHCOA and
shared their memories of the event with
Caring for the Ages.
Before the Internet
When AMDA first heard that the White
House was planning a conference for
1995, Dr. Tangalos recalled, leadership
saw this as an important opportunity
and jumped into action.
“This was before we had laptops, tablets, and cell phones; so much of the
work we did was via phone and personal
meetings,” he said. The AMDA leadership saw the meeting as a way to get
its members, specifically state chapters,
involved on a national level and bring
attention to key issues for PA/LTC practitioners and their patients.
“Our state chapters were just getting
organized, and we had them submit
ideas and topics for discussion at the
conference. Having the chapter participate gave them a theme for the year and
a way to rally the troops,” Dr. Tangalos
said. “The states really got behind us,
and they were very responsive.” Among
the topics suggested by the states were
workforce issues, patient safety, and endof-life care.
Robert Blancato was the conference’s executive director, and AMDA’s
leaders met him the first week he was
appointed to pledge AMDA’s support.
Two committees – a program committee and a policy committee – were
charged with the WHCOA’s overall
operation. Members of both committees were determined by presidential
appointment. The program committee
consisted mostly of congressional and
White House staff. However, the policy
committee was a broader, more diverse
group; and Dr. Tangalos was one of
only two physicians appointed to this
group. The other physician was Robert
Butler, MD, the late gerontologist, psychiatrist, and Pulitzer Prize-winning
author.
“I was in DC every 3 weeks for
18 months to work on this committee.
These were exciting times, and there
was a strong focus on health care legislatively,” Dr. Tangalos said. “Being
involved on the WHCOA was fascinating, and I had memorable meetings
with the President and Mrs. Clinton,
the Gores, and others. It was a great
opportunity to get involved in policy
development, and it eventually led to
my appointment to the national board
of the Alzheimer’s Association.”
AMDA rallied around the conference
and worked to get members appointed
as delegates from their states. Among
these was Dr. Cranmer, who was a
delegate from his home state of
Oklahoma.
States Shake Things Up
“We started to get excited about the
conference well before it happened. In
Oklahoma, we decided to have a statewide pre-WHCOA meeting with our
state chapter and the Oklahoma Medical
Association. Bob Blancato was there, and
we had about 350 people,” Dr. Cranmer
recalled.
Dr. Cranmer has several powerful memories from the ’95 WHCOA.
“Perhaps the most significant take-home
message was that 40% of the voters
in America were over 65 and that we
wouldn’t see Medicaid and Medicare go
away any time soon.” He also recalled
a meeting between Dr. Tangalos and
the last living survivor of the group of
soldiers memorialized on the Iwo Jima
Memorial.
“Eric met him at a hospitality suite
the night before President Clinton was
to address the meeting, and he was
impressed by the man,” Dr. Cranmer
said. Dr. Tangalos was scheduled for
a 30-minute one-on-one meeting with
the President that week, and he let the
veteran take his meeting. “It was such
a gracious gesture. I still smile when I
think about it today.”
Palliative care and end-of-life issues
have received tremendous attention
in recent years, but they were less
defined and more controversial in ’95.
Dr. Cranmer was determined to move
the conversation on these topics forward. “I was very passionate about these
issues and took the lead on discussing
them. It wasn’t an easy discussion,”
Dr. Cranmer said. He promoted the
benefit of advance directives and donot-resuscitate orders. Other delegates
were adamant that issues like these, as
well as guardianships and surrogate decision makers, were wrong. “They were
saying, ‘No, no, no. Don’t give up your
rights,’ ” he noted.
Although there was no final resolution
to these issues during the conference,
Four Key Issues
Emerge for
2015 WHCOA
To date, 2015 WHCOA organizers have identified several issues
that likely will form the basis of
discussion at the conference. These
include:
▶ Retirement security – how older
Americans can save for retirement,
how to enable older people who
want to work to do so, and how to
preserve Social Security.
▶ Healthy aging – how government, business partners, and others
can help older Americans to live
healthier lives and reduce the risk of
disease, accidents, and injuries.
▶ Long-term care services and
supports – how to improve and
promote services and supports that
enable elders to stay in their homes,
afford the care they need, and enjoy
quality of life.
▶ Elder justice – how to protect
elders from abuse, neglect, and
financial scams.
the conversations served to bring them
national attention. “We’ve made great
strides. While they haven’t come as far
or fast as we would like, it might have
taken longer if not for us addressing endof-life issues at the WHCOA,” he said.
He added that one of the last speakers
at the conference observed that out of
440 medical institutions in the country,
there were fewer than 40 geriatric programs and zero palliative care programs.
“It was great to have this recognized,”
Dr. Cranmer said.
“The first WHCOA in 1961 brought
us Medicare. Nothing has come close
since, but the ’95 conference strengthened AMDA’s state chapter program,
got a national platform for our organization, and brought attention to key
issues of concern to PA/LTC practitioners,” Dr. Tangalos said. “AMDA’s
visibility soared with the ’95 WHCOA.
We had great years following this with
more involvement with CMS – then
HCFA – and a strong presence on the
national stage. We grew quickly in the
years that followed, partly because of
the strengthening of the state chapters that occurred because of the
conference.”
The WHCOA “forced people to
start identifying and discussing issues
such as end-of-life care and the need to
ensure an adequate workforce. People
were worried and anxious about the
future, and the conference made
them focus on the facts and consider
opportunities for positive change,”
Dr. Cranmer said.
For more information about the 2015
WHCOA, go to www.whitehouseconferenceonaging.gov.
CfA
Senior contributing writer Joanne Kaldy
is a freelance writer in Harrisburg, PA, and
a communications consultant for AMDA
and other organizations.
AMDA Foundation’s
2015 Caring Canines Calendar
is h
here!
e e!
Order Now!
Only
$16.95*
(plus shipping)
Our 12-month, full-color
calendar features dogs and
other furry friends with their
human friends selected from long-term care
facilities from across the country. It’s a perfect
holiday gift and a great way to support the
Foundation’s long-term care research and
education projects.
*Discounts available when purchasing multiple copies
Find out more at www.amdafoundation.org/canines
16 • CARING FOR THE AGES
FEBRUARY 2015
Alirocumab Reduced LDL, Major CV Events
BY BRUCE JANCIN
W
hen added to maximally tolerated statin therapy, the
investigational PCSK9 inhibitor alirocumab resulted in a further 54%
reduction in major cardiovascular events
among high-CV-risk patients, based on a
post-hoc analysis of a large randomized
controlled phase 3 trial.
“This is the first trial with any of the
PCSK9 inhibitors to suggest that there
will be a further significant reduction in
cardiovascular events when added on to
maximized statin therapy,” Jennifer G.
Robinson, MD, professor of epidemiology and medicine, and director of the
prevention intervention center at the
University of Iowa, Iowa City, said in
presenting interim results of ODYSSEY
LONG TERM at the annual congress
of the European Society of Cardiology.
Sanofi and Regeneron bought a
$67.5 million voucher to hasten the FDA
regulatory review process of the drug.
The proposed indication will be for
LDL-lowering, which regulatory agencies have accepted as a surrogate endpoint for prevention of clinical events.
Meanwhile, the definitive ODYSSEY
OUTCOMES trial is underway in 18,000
patients with acute coronary syndromes,
with prospective evaluation of CV outcomes as its primary endpoint.
ODYSSEY LONG TERM includes 2,341
patients at high CV risk and an LDL level
Caring for consumers
What Exactly Is Assisted Living?
Pennsylvania post-acute/long-term care physician Daniel Haimowitz, MD, CMD, talks about
assisted living facilities and which individuals are likely to do best in this care setting.
Assisted living facility or nursing home? This is a
common question when one is considering postacute/long-term care.
additional costs may be involved for things like
medication assistance. Costs may vary widely from
facility to facility, even within the same state or town.
Generally, people in assisted living are capable of
living independently with some help and support
with various activities of daily living (e.g., bathing or dressing). Some facilities may offer help
with medications, whereas others require that
residents be able to take their own medications
without help or reminders.
Your physician can help you decide what care setting is best for you or your loved one. However, if
your family member or friend is frail and steadily
or quickly declining mentally and/or physically,
he or she may be a candidate now for assisted
living but may not in a few months. Although a
nursing home may not be your preference, it may
be the best choice to keep your loved one safe
and happy.
Assisted living communities do not offer complete
medical services and generally have limited clinical
staff. In some communities, a physician is available onsite. Most have full- or part-time nursing
staff. However, unlike a nursing home, where many
illnesses and injuries can be treated onsite, most
assisted living facilities have to send residents to
the hospital or doctor’s office if they get sick or hurt.
Originally started as a social care model, assisted
living facilities offer housing that is more like
what people would have in the community, such
as apartments or cottages. They often feature
kitchenettes with small refrigerators, microwaves,
and sinks. As well, assisted living facilities have
dining halls where residents can come for meals
and snacks, and there are housekeeping, laundry,
and transportation services available. Some may
even have pharmacies, barbers, physical therapy
service, and beauticians onsite. Others may be
small mom and pop operations – group-like homes
or personal care homes with just a few beds.
Some retirement communities offer both a nursing
home and an assisted living facility. That commonly
is called a continuing care retirement community,
or CCRC, because it provides settings that have
more health care available to take care of residents
as they get sicker and need more attention.
Rules and regulations for assisted living facilities,
unlike nursing homes, differ from state to state.
Find out what services the facility offers and what
™
▶ Questions To Ask Your Practitioner
• How much help/care do I or my loved one need?
Is medication assistance necessary?
• What is my or my loved one’s cognitive/mental
status?
• How quickly might mental/physical health be a
concern?
• What support/services should I look for?
▶ What You Can Do:
• Talk to your physician or other practitioner about
care/living options for you or your loved one.
• Visit facilities and talk to staff.
• Talk to your loved one about what is important
to him/her and what his/her fears, concerns, etc.
are about moving into a post-acute/long-term care
community.
• Find out how what costs are involved and how
you will be expected to pay for care.
▶ For More Information:
• Choosing a Senior Care Community:
www.alfa.org/alfa/Choosing_a_Community1.asp
• What To Look For, What To Ask When
Choosing Assisted Living: www.caring.com/
articles/assisted-living-facilities-choosingthe-right-one
• Nursing Home vs. Assisted Living:
www.guidetonursinghomes.com/nursing-homes/
assisted-living-nursing-homes.html
CARING FOR THE AGES is the official newspaper of AMDA – The Society for Post-Acute and Long-Term Care Medicine and provides postacute and long-term care professionals with timely and relevant news and commentary about clinical developments and about the
impact of health care policy on long-term care. Content for CARING FOR THE AGES is provided in part by Frontline Medical News and
by writers, reporters, columnists, and editorial advisory board members under the editorial direction of Elsevier and AMDA.
The ideas and opinions expressed in CARING FOR THE AGES do not necessarily reflect those of the Association or the Publisher.
AMDA – The Society for Post-Acute and Long-Term Care Medicine and Elsevier Inc., will not assume responsibility for damages,
loss, or claims of any kind arising from or related to the information contained in this publication, including any claims related
to the products, drugs, or services mentioned herein.
©2015 AMDA – The Society for Post-Acute and Long-Term Care Medicine.
greater than 70 mg/dL despite maximally
tolerated statin therapy. Patients either
have heterozygous familial hypercholesterolemia or are at very high risk due to
known coronary heart disease. Participants
were randomized 2:1 to 150 mg of alirocumab by self-administered subcutaneous injection at home every 2 weeks, or to
placebo in addition to their statin.
At 65 weeks, the combined rate of
cardiac death, nonfatal myocardial
infarction, stroke, and unstable angina
requiring hospitalization was 1.4% in the
alirocumab arm compared with 3.0% in
placebo-treated controls.
At 24 weeks, the alirocumab group
showed a mean 62% reduction in LDL
compared with placebo. The average LDL
level at 52 weeks in the alirocumab group
was 53 mg/dL, down from 123 mg/dL
on active treatment at baseline. An LDL
below 70 mg/dL was achieved by 79% of
alirocumab-treated patients.
In a separate presentation, Michel
Farnier, MD, reported on the use of
alirocumab in 735 patients with heterozygous familial hypercholesterolemia in
two Phase 3 trials known as ODYSSEY
FH I and FH II. At baseline, all were
above their LDL goal despite maximally tolerated statin therapy and, in
two-thirds of cases, took add-on ezetimibe. Participants were randomized 2:1
to add-on alirocumab at 75 mg every
2 weeks or to placebo.
The alirocumab-treated patients had
58% and 51% reductions in LDL compared with actively treated controls at
24 weeks in the FH I and FH II trials.
Of alirocumab-treated patients, 72% and
81% achieved their prespecified LDL
goal at 24 weeks; of controls, 2% and
11% met their goal.
Christopher P. Cannon, MD, reported
that alirocumab outperformed ezetimibe
as add-on therapy in the 720-patient,
Phase 3 ODYSSEY COMBO II trial.
In this study, patients at high CV risk
who were unable to reach their desired
goal of an LDL below 70 mg/dL
were randomized 2:1 to alirocumab at
75 mg once every 2 weeks or oral ezetimibe
at 10 mg/day as an active comparator.
By week 24, patients on alirocumab
plus a high-dose statin averaged a 51%
reduction in LDL compared with baseline, compared with a 21% reduction
with ezetimibe plus statin.
Of patients on alirocumab, 77% achieved
an LDL goal of less than 70 mg/dL at
week 24, compared with 45% on ezetimibe. LDL was below 50 mg/dL in 60%
of the alirocumab group and 15% of the
ezetimibe group.
Most patients (85%) in ODYSSEY
COMBO II were adherent to the biweekly
self-injection protocol through 1 year,
noted Dr. Cannon, professor of medicine
at Harvard Medical School, Boston.
“That has been a pleasant surprise,”
he said. “The notion of injections for
cholesterol management is foreign. It
was a surprise to us that patients really
did it.”
CfA
Bruce Jancin is with the Denver bureau
of Frontline Medical News.
CARING FOR THE AGES •
CARINGFORTHEAGES.COM
Home Care
from page 1
including a quality program, appeal
and grievance rights, reasonable access
to providers, and the right to change
plans. States can use either a state plan
or waiver authority to establish their
Medicaid managed care plan, as long
as they comply with these regulations.
Medicaid managed care may involve
managed care organizations that provide benefits in exchange for a monthly
payment from the state, or it may be
a limited benefit plan that resembles a
health maintenance organization and
provides specific benefits, such as mental health care. Alternately, a state’s
Medicaid managed care program may
involve primary care case managers
who receive monthly payments for
care coordination, referrals, and various medical services.
What Practitioners Should Know
Although Medicaid managed care
doesn’t affect how facilities care for
residents or how practitioners provide
care, it likely will impact lengths of stay,
patients’ movement through the care
continuum, and the use of home- and
community-based supports and services.
So what does Medicaid managed care
mean for practitioners?
“Physicians, nurse practitioners,
and physician assistants likely will see
more efforts to convert and transition
Principles
of Care
In a Medicaid Managed Care Long
Term Services and Supports State
Affiliate Primer, Toolkit and Resource
Guide, Mike Cheek and Christopher
Puri, an attorney at Bradley Arant
Boult Cummings, LLP, in Nashville,
TN, identified several principles to
ensure access, choice, and quality for
residents and patients in Medicaid
managed care, or MLTSS:
1. MLTSS must improve access and
quality first.
2. States and plans should possess
demonstrated experience before
implementing or expanding MLTSS.
3. States should offer individuals
meaningful opportunities to make
educated decisions.
4. Independent grievances and
appeals processes for individuals and
providers should be established and
adequately funded.
5. MLTSS arrangements should
ensure access to care when patients
and residents need it.
6. Ensuring administrative efficiency and consistency across plans is
essential.
7. Care coordination should produce efficiencies while improving
health care experiences.
8. Consider all views and perspectives when crafting MLTSS
programs.
9. Align provider reimbursements
with program standards and access
goals.
people out of long-term care facilities
and into home-based care and community settings,” according to Mike Cheek,
American Health Care Association vice
president of Medicaid and long-term
care policy. Practitioners will need to
start working with case managers and
others connected to Medicaid managed care plans to focus on transitioning some patients out of long-term
care settings and diverting others from
post-acute back to the community, he
said. Mr. Cheek added that practitioners
should realize that this will spell the end
for Medicaid fee-for-service in states that
adopt Medicaid managed care.
‘Physicians, nurse
practitioners, and
physician assistants likely
will see more efforts to
convert and transition
people out of long-term
care facilities and into
home-based care and
community settings.’
“This represents a change in care,”
Mr. Cheek told Caring for the Ages,
and practitioners should be “deeply concerned. If people go from post-acute to
long-stay then sent home and something
happens that requires them to go back
to the hospital, this has repercussions
for both the hospital and the practitioner,” he explained. “Providers [such as
hospitals or nursing homes], provider
networks, and practitioners will be held
accountable.”
Practitioners will still oversee care
decisions. “Plans are required to respond
to physicians’ input on medical decisions,” said Mr. Cheek. However, he
added, “Whether they accept this input
is another matter.” Practitioners can
make the most of their input by working
closely with the interdisciplinary team as
patients are transitioned.
“One role that physicians are being
asked to fill in Medicaid managed care
regards documentation of functional
status,” added Melinda Henderson,
MD, CMD, FAAHPM, senior clinical
medical director at United Healthcare
in Nashville, TN. “Plans are asking physicians to provide specific details about
issues such as how patients are ambulating, transferring, and walking. This is
important as ability to perform activities
of daily living is a core component of
eligibility for Medicaid.”
Everything Old Is New Again
Ten years ago, Dr. Henderson said, “I
always thought of managed care as
focused on utilization management –
that was its major mechanism. Then
5-8 years ago there was a realization that
utilization management wasn’t enough,
and we saw a bigger push regarding
disease management.” Disease management programs began popping up, and
there has been a greater emphasis on
hands-on care that encourages patients
to participate in managing their illnesses. Now, with Medicaid managed
care, disease management is partnered
with other initiatives that enable patients
to utilize the lowest level of care for
as long a time as possible – all without avoidable emergency room visits or
hospitalizations.
Dr. Henderson observed that the
effort to divert patients away from longterm nursing home stays isn’t new, and
it is the way of the future. “It used to be
that the nursing home was the end of
the road. Patients were admitted, and
they spent their remaining days there,”
she said. In recent years, the rise of postacute has supported the idea that many
elders can return to the community after
an illness, surgery, or injury.
Nonetheless, barriers may prevent
many patients from returning to their
homes. For instance, Dr. Henderson
said, “We had a significant waiting list
for home care services in our state, so
many patients had to remain in nursing
homes and were resigned to the idea
that they’d be there forever.” However,
“Ultimately, it’s the patient’s decision.
We can’t force people out just because
we think someone could be cared for
less expensively in the community,” she
said.
Medicaid managed care programs are
designed to eliminate the barriers to
patients returning to the community
17
and enable access to the supports and
services that will make this possible. “If
patients have unmet social needs – for
example, they’re not getting meals or
their homes are falling into disrepair,
these things can lead to physical or mental decline that results in rehospitalizations,” Dr. Henderson told Caring for
the Ages. In post-acute/long-term care,
this means identifying and wrapping
the right supports around individuals so
that they can maintain healthy living in
the community. She noted, “How such
systems are structured depends on the
state. In Tennessee, we are responsible
for beneficiaries wherever they are,
so we are trying to identify individuals who want to move out of nursing
homes. Then we are working to determine what supports and services will
make that possible.”
Dr. Henderson and Mr. Cheek urge
practitioners to find out about Medicaid
managed care programs in their states.
Then, they suggest working with their
facilities to strengthen care planning,
processes, and documentation so that
patients who want and are able to return
the community have the resources, supports, tools, and knowledge to remain
there safely.
CfA
Senior contributing writer Joanne Kaldy
is a freelance writer in Harrisburg, PA, and
a communications consultant for AMDA
and other organizations.
KENTUCKY INTERNATIONAL
CONVENTION CENTER
4XDOLW\
on7UDFN
Pre-Order & D
Save! CME/CM
ble!
Credit Availa
Pre-order your online library
subscription to the session recordings
by March 2, 2015 and take advantage
of the special pre-conference rates!
2QOLQH/LEUDU\
Experience AMDA’s 2015 Annual Conference sessions anytime, anywhere!
Create a username and password, browse sessions, stream or download the entire
session! All sessions are synchronized with the audio and presentation materials.
CME/CMD credits available for 2015 sessions!
0XOWLPHGLD'9'520
Experience AMDA’s 2015 Annual Conference sessions from the comfort of
your own home. All DVD-ROM sessions are synchronized with the audio and
presentation materials.
&RQIHUHQFH6SHFLDO
Get both the online library & DVD-ROM of the AMDA’s 2015 Annual Conference
sessions. CME/CMD credits available for 2015 sessions on the online library.
0XOWL<HDU2QOLQH/LEUDU\
Missed any of the previous AMDA Meetings? No Problem! Digitell has over 600
educational sessions from the 2004-2015 Meetings! CME/CMD credits are available
for the 2012, 2013, 2014 and 2015 sessions. Experience the sessions anytime,
anywhere! Create a username and password, browse sessions, stream or download
the entire session!
To Pre-Order Online Library visit: www.prolibraries.com/amda
To Pre-Order DVD-ROM call: 1-800-679-3646
$199.00
Post Conference: $395
$199.00
Post Conference: $395
$249.00
Post Conference: $445
$495.00
Post Conference: $595
™
18 • CARING FOR THE AGES
FEBRUARY 2015
N E W S
F R O M
T H E
S O C I E T Y
Use Scheduler To Get the
AMDA Leaders Address
Most From AMDA Conference Competencies in New Article
™
in action
Guests Welcome at Annual
Conference
A
MDA offers a Companion and
Spouse Travelers (C.A.S.T.) Program for PA/LTC professionals traveling to Louisville with a spouse, guest,
or sponsor. This program not only lets
guests enjoy Louisville attractions and
tours but also reunites many C.A.S.T.
members from previous years.
The C.A.S.T. Program is open
to all spouses and guests of meeting attendees, 18 years old and up.
Pre-registration ends Feb. 25, and
attendees may register for 3 or 4 days.
Those wishing to register after Feb. 25
may do so onsite, but some tours may
be sold out at that time.
Program highlights include:
▶ Thursday Daily Tour – Louisville
Legends: Journey along historic
Main Street, including stops at the
Muhammad Ali Center and the
Louisville Slugger Museum, home of
the world’s largest baseball bat.
▶ Friday Daily Tour – Wild Turkey
Distillery: Guests will travel through
beautiful bluegrass country to one of
Kentucky’s legendary bourbon distilleries. Located near the Kentucky
River Gorge is the new Wild Turkey
Visitors’ Center, where guests will
learn the history of bourbon, see
production at the recently expanded
distillery, and enjoy a Wild Turkey
bourbon tasting.
▶ Saturday Daily Tour – Horses
and History: Guests will enjoy a tour
of Churchill Downs and a southern
breakfast on the backside, while
enjoying the morning workout of the
thoroughbreds. Following a walking
tour of the racetrack, guests will then
visit the Kentucky Derby Museum
on the frontside. Later, enjoy a walk
through the historic preservation
district, where many stately Victorian
mansions and homes retain their 19th
century charm.
For more information, visit
www.paltcmedicine.org/spouseguestprogram/.
CfA
A
Nursing Home Celebrates
Caring Canines
“T
here are three things that our
residents have a universally
and significant response to – music,
children, and animals,” said J. Kenneth
Brubaker, MD, CMD, medical director
of Masonic Village in Elizabethtown,
PA. The facility, which is featured in
the 2015 AMDA Foundation Caring
Canines calendar, held a special event
to celebrate the honor.
Dr. Brubaker was joined by Ruth,
the resident who appears with him in
the calendar photo, and Bubble, the
long-haired Chihuahua that is Ruth’s
frequent visitor and friend. Ruth’s son
and daughter-in-law were on hand,
as was Bubble’s owner and Masonic
Village volunteer Joanne Kaldy.
Various residents and staff members
also stopped by. The group even
received a visit from Santa.
AMDA Staff Shares Gift With
Masonic Village Residents
D
uring the recent holiday season,
AMDA staff collected fleece
throws, slippers, word game books,
picture frames, and other gifts for
residents at Masonic Village in Elizabethtown, PA, where AMDA board
member and former Medical Director
of the Year J. Kenneth Brubaker, MD,
CMD, is medical director.
“We really appreciate AMDA’s
generosity. It was so nice of them to
domains: foundation, medical care
delivery process, systems, nursing
home medical knowledge, and personal quality assurance and performance improvement.
The authors noted that “the goal of
the competency initiative is to define
the skills necessary for effective and
high-quality practice in the nursing
home and not to create barriers to practice. Although a certification process
may evolve in the future – an American
Medical Director Certification Program
work group has recently been constituted to explore this issue – the primary
intent is to recognize and further professionalize [nursing home] practice.”
To read the article, go to
www.annalsoflongtermcare.com/
article/examining-rationale-and-processes-behind-development-amda’scompetencies-post-acute-and-long. C
fA
MDA leaders Paul Katz, MD, CMD,
Matthew Wayne, MD, CMD, Jonathan Evans, MD, CMD, and Leonard
Gelman, MD, CMD, along with AMDA
staff member Sheena Majette, addressed
AMDA’s new attending physician
competencies in the article, “Examining
the Rationale and Processes Behind
the Development of AMDA’s Competencies for Post-Acute and Long-Term
Care,” published in the November 2014
issue of Annals of Long-Term Care.
The article addressed the framework, principles, and scope of the
competencies, as well as the principles
guiding competency development.
This process included the establishment of a 25-member AMDA work
group, which drafted competencies
that were reviewed by 450 AMDA
members via online survey. The final
competencies included five general
think of our residents,” said Masonic
Village recreation therapist Nessie
Denton. “We enjoyed collecting
items to share with the residents, said
AMDA staff member Debbie Addison.
“Our members do such a great job
all year long of caring for residents.
We were pleased to play a small role
in paying tribute to our elders who
are in post-acute and long-term care
Ruth holds tight to frequent visitor
facilities.”
CfA Bubble.
J K ENNETH B RUBAKER
custom schedule that they can print
or e-mail to themselves, colleagues,
or staff. By creating an account, users
can store their schedule in the conference scheduler and then retrieve
it and revise it at any time. To create and customize
your schedule, go to
www.paltcmedicine.
org/custom-meetingschedule/.
The scheduler
does not guarantee
access to education
sessions at the meeting. All sessions,
including the preconference intensive sessions, are first-come, firstserved, with the exception of ticketed
sessions.
CfA
COURTESY OF
MDA member Dan Steiner, MD,
CMD, gets a lot out of the AMDA
annual conference because he plans
ahead. “I look through the program
and identify programs I can get
CMD credit for – that’s key. Then I
look for topics that
interest me – I like
the policy and legal
programs, and I can’t
get enough information about wound
care,” he said. You
can plan ahead too
by customizing your conference activities through AMDA’s conference
scheduler.
The scheduler is a tool to help
meeting attendees create their own
P HOTOS
A
J. Kenneth Brubaker, MD, CMD,
Ruth, and Bubble celebrate their
appearance in the AMDA Foundation
Caring Canines calendar.
“Bubble and I have a special bond,”
said Ruth. “The pet visits have
become very important to mom,”
Ruth’s son added. “She really looks
forward to her time with Bubble.”
As the group chatted and ate a cake
featuring the picture from the calendar, Ruth’s daughter-in-law sent photos of the event to family members
and read their responses as they came
in. “Everyone is thrilled for mom and
excited about the calendar,” she said.
Get your copies of the AMDA
Foundation Caring Canines calendar
at www.caringcaninescalendar.com.
Proceeds support the Foundation’s
popular and important Futures
Program.
CfA
CARING FOR THE AGES •
CARINGFORTHEAGES.COM
19
N E W S
F R O M
T H E
S O C I E T Y
Auction Features Heavy Hitters Help Celebrate the 2015
It’s not too late to make a conSwagerty, MD, CMD, Jeffrey
Medical Director of the Year
tribution to the auction. Contact the
Levine, MD, Barbara Resnick,
Daniel
PhD, CRNP, Jason Karlawish, MD,
Louise Aronson, MD, George Rodrigue,
Amy Tam, Ira Byock, MD, and David
Dosa, MD – these are just a few of the
prestigious authors who will be featured
in the AMDA Foundation Auction at
the Wall during AMDA’s annual conference in Louisville, KY, next month.
Foundation if you’ve written a book,
have a rare or interesting tome, or have
an author-signed book. We also welcome items such as new toys and games,
DVDs, CDs, and portable electronics.
To arrange your donation, contact the
AMDA Foundation at [email protected] or 410-992-3134. C
fA
AMDA Works With SHM
on New Toolkit
A
MDA board member and Caring
for the Ages Editor in Chief
Karl Steinberg, MD, CMD, was
part of a work group that developed a Post-Acute Care Transitions
Toolkit, published recently by the
Society of Hospital Medicine. The
kit includes a variety of resources
to help optimize the care transition
processes between short-term acute
care hospital stays and skilled nursing facility stays. The kit’s approach
is based on the principles of quality
improvement applied to this specific
transition. The interventions within
the toolbox are derived from both
evidence-based medicine and the
experiences of institutional experts.
In addition, it includes a section on
resources, programs, and innovations developed by professional
societies, governmental agencies,
and businesses.
“It was nice to have different stakeholders work together on this important
topic, a topic that has been an AMDA
priority for several years. It was important for us to have a place at the table
in the development of this kit, and our
AMDA people made a significant impact
on the final product. I was pleased to be
a part of this,” said Dr. Steinberg.
For more information on the toolkit, go to www.hospitalmedicine.org/
and click on Quality & Innovations.
Follow the drop down menu to
Implementation Toolkits and choose
from there.
CfA
T
imothy Malloy, MD, CMD, was
the first to win AMDA Medical
Director of the Year title in 2007, but
the award is still meaningful for him
today. “I still feel honored to have
won this recognition. It was tremendous affirmation of what I’d been
doing for years,” Dr. Malloy said.
He encourages team leaders to
nominate their outstanding physician leaders for the distinction. “It
creates a lot of goodwill between
the facility and the medical director,
and I know there are many medical
directors out there who are doing
outstanding work,” he said. “It will
mean a great deal just to be nominated. I would have felt honored even
if I didn’t win.”
Help us honor the 2015 Medical
Director of the Year during the
AMDA annual conference on Friday,
March 20, at 8:00 a.m. Watch for
brief bios of the nominees in next
month’s issue of Caring for the
Ages, and read an interview with
the award recipient in the May
issue.
Dr. Malloy observed that the award
not only made him feel good; it also
helped open doors to other rewards.
“It gave me an extra level of credibility. An excellent facility was being
built in my area, and I really wanted
to become medical director on its
completion. I got the job, partly
because of this award.”
Daniel Mendelson, MD, CMD, a
colleague, mentee, and friend of
the late Rocco Vivenzio, MD, CMD,
who was Medical Director of the
Year in 2013, said, “There are a lot
of good, under-recognized people
who deserve this award. If you look
around, you can recognize those
colleagues who you look up to,
who have fought the good fight,
and who have made a tremendous
difference in people’s lives every
day.”
The award meant a great deal to
Dr. Vivenzio, who died shortly after
he received the honor. “It was very
humbling and emotional for Rocky.
It was validation for a body of work
that meant something to him,” said
Dr. Mendelson. “Rocky was thankful for all of the colleagues who
provided their own leadership and
those who came after him to make a
difference.”
If Dr. Vivenzio was here today,
Dr. Mendelson said, “He would be
honored that we’re still talking about
him and his legacy. He would be
thankful that most of what he’s done
has survived him and is continuing to
grow and thrive.”
CfA
Don’t Miss These Events
Now-March 2, 2015
AMDA Core Curriculum on Medical
Direction in Long-Term Care: Part I
Online Session 1
Contact: AMDA Registrar
Phone: 410-992-3116
E-mail: [email protected]
Website: www.amda.com/cmedirect/
core-part-1.cfm
March 21, 2015
Meet the Expert Breakfast Session:
Movement Disorders in the
Older Adult
Louisville, KY
Contact: AMDA Registrar
Phone: 410-992-3116
Email: [email protected]
Website: http://bit.ly/meethexperts
March 19, 2015
Navigating Mood and Behavior
Challenges Workshop
in Conjunction With AMDA’s
Annual Conference
Contact: AMDA Registrar
Phone: 410-992-3116
Email: [email protected]
Website: www.bit.ly/moodbehavior
March 27-28, 2015
GAPNA: Contemporary
Pharmacology and
Prescribing in Older
Adults
Philadelphia, PA
Contact: Jill Brett
Phone: 866-355-1392
Email: [email protected]
Website: www.gapna.org
March 19-22, 2015
AMDA – The Society for
Post-Acute and Long-Term
Care Medicine 2015 Annual
Conference
Louisville, KY
Contact: AMDA Registrar
Phone: 410-992-3116
Email: [email protected]
Website: www.paltcmedicine.org
April 6-June 1, 2015
AMDA Online Core Curriculum on
Medical Direction in Long-Term
Care: Part I Online Session 2
Contact: AMDA Registrar
Phone: 410-992-3116
Email: [email protected]
Website: www.amda.com/cmedirect/
core-part-1.cfm
Important
ant
Dates
Dat
April 1, 2015
AMDA CMD Initial and
Recertification Deadline
Contact: AMDCP Program
Manager
Phone: 410-992-3117
Email: [email protected]
Website: www.amda.com/certification/
overview.cfm
April 24-25, 2015
2015 CALTCM Annual
Meeting
Los Angeles, CA
Contact: Barbara Hulz
Phone: 888-332-3299
Email: [email protected]
Website: www.caltcm.org
May 5-6, 2015
NYMDA Spring 2015 Meeting
Albany, NY
Website: nymda.org/educationalmeetings/spring-2015-meeting/
May 15-17, 2015
American Geriatrics Society 2015
Annual Scientific Meeting
National Harbor, MD
Website: www.americangeriatrics.org/
annual_meeting/
June 6-10, 2015
NADONA 28th Annual Conference
Atlanta, GA
Website: www.nadona.org
July 18-24, 2015
AMDA Core Curriculum on Medical
Direction in Long-Term Care
Baltimore, MD
Contact: AMDA Registrar
Phone: 410-992-3116
Email: [email protected]
Website: www.amda.com/education/core
September 30-October 3, 2015
GAPNA: Annual Conference
San Antonio, TX
Contact: Jill Brett
Phone: 866-355-1392
Email: [email protected]
Website: www.gapna.org
March 17-20, 2016
AMDA – The Society for Post-Acute
and Long-Term Care Medicine
2016 Annual Conference
Kissimmee, FL
Contact: AMDA Registrar
Phone: 410-992-3116
Email: [email protected]
Website: www.paltcmedicine.org
™