Geriatric Nursing 35 (2014) 65e68
Contents lists available at ScienceDirect
Geriatric Nursing journal homepage: www.gnjournal.com
Assisted Living Column
Richard G. Stefanacci
Dan Haimowitz
The ins and outs of ALCs Richard G. Stefanacci, DO, MGH, MBA, AGSF, CMD a, b, c, *, Dan Haimowitz, MD, CMD, FACP d, e, f a
Health Policy & Public Health, University of the Sciences in Philadelphia, PA, USA The Access Group, USA Mercy LIFE, Philadelphia, PA, USA d Private Practice, Levittown, PA, USA e Arden Courts of Yardley, PA, USA f Brunswick at Attleboro, Langhorne, PA, USA b c
Financial survival for Assisted Living Communities (ALCs) is based in large part on its occupancy rates. In basic terms this level is based on getting AL residents into the facility and keeping them there. While the AL nursing staff may think that this number game is solely the responsibility of the bean counters within the ALC, this thinking would be wrong. ALCs have come a long way from their start when they were birthed from hotel companies thinking that ALCs were an extension of the hospitality business. These companies, Marriott and Hyatt, are no longer in the AL business. Instead, companies with a foundation in health care are now firmly in charge. This is because AL residents today seem more interested in assistance in their health care than in the hospitality services being offered, although the variety and quality of meals still ranks very high in AL selection decisions. With this focus on health care it’s clear that demonstrating the value of high quality medical care along with preventive services can only be accomplished with the leadership and support of the AL nursing staff. In this article we will examine the payment for ALCs, what it takes to get a resident in and keep them within the facility. When thinking about the role of nurses in getting and keeping residents one must start with understanding how ALs are paid.
* Corresponding author. Health Policy & Public Health, University of the Sciences in Philadelphia, PA, USA. E-mail address: [email protected] (R.G. Stefanacci). 0197-4572/$ e see front matter Ó 2014 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.gerinurse.2013.11.007
Financing ALCs are primarily paid privately through individual’s own resources. In recent years these resources have taken a significant hit as home values and personal assets have markedly lessened due to the weakened economy. However, beyond one’s personal resources there are a growing number of avenues to fund ALCs. Some of these include LTC insurance or state programs that look to avoid the expense of skilled nursing facilities some of which can cost 3e4 times that of an ALC. Congress had attempted within the Affordable Care Act to introduce an LTC option for Americans. This was included under the Community Living Assistance Services and Supports Act (or CLASS Act),1 a U.S. federal law, enacted as Title VIII of the Patient Protection and Affordable Care Act. The CLASS Act would have created a voluntary and public long-term care insurance option for employees, but in October 2011 the Obama administration announced this insurance option was unworkable and would therefore be dropped. The CLASS Act was formally repealed on January 1, 2013. Although the CLASS Act failed, the Commission on Long-Term Care issued a report to Congress in September 2013 providing recommendations for long-term care reform.2 They issued two alternative approaches of financing long-term services and supports (LTSS) reform: 1) via private options and 2) via a public, social insurance option. The two public options were 1) creating a comprehensive Medicare LTSS benefit or 2) creating a basic LTSS benefit as part of Medicare Part A or in a new public program. A public option through Medicare would significantly increase the
66
R.G. Stefanacci, D. Haimowitz / Geriatric Nursing 35 (2014) 65e68
number of older adults able to afford LTC services including AL services. Beyond LTC insurance there are also state programs that are looking to provide coverage for AL care. These include opportunities through Home & Community based waivered programs and managed care programs such as Managed Medicaid and PACE. All of these programs look to move care to outside of the skilled nursing facility to alternative sites including AL. Whether it is the decision of the resident or families using their own funds or an outside organization like an MCO making the call creating and demonstrating value is critical. Assisted care Of course even with a source of funds either personal or public, older adults still need to decide if a particular ALC is right for them. To that end, an increasing number of older adults are relying on the variety and quality of Clinical Services to base their decision. These services typically fall into three categories: acute care, maintaining, and chronic disease management. On the chronic disease state management side these services include the management of diabetes, CHF, COPD and Alzheimer’s diseases. Many AL residents suffer from chronic comorbid conditions; in fact, it is often a progression of these conditions that prompts their move to an ALC. Because of this, ALCs are evaluated by potential residents on their ability to deliver quality chronic disease management. This management relies on careful medication management, monitoring of red flags, regular primary care provider follow-up and preventive care initiatives. These initiatives were identified as needed steps to prevent avoidable hospitalizations from occurring. As a result ALCs are well served in establishing comprehensive chronic disease management programs that incorporate these elements. Of course, sometimes acute care services are needed in AL to avoid an ER visit. Acute care services within an ALC can run the gambit from a physician’s office to a provider that can make urgent house calls. Technology is making it such that providers can make virtual or telemedicine bedside calls to AL residents in need of acute care services. One recently introduced services that provide acute hospital-level care to patients residing in LTC facilities. Physicians can now use state-of-the-art telemedicine technology to interview, examine and treat LTC residents when their usual physicians are not available. By treating patients on site, an AL facility can avoid unnecessary hospitalizations, improve clinical outcomes, and increase resident and family satisfaction. In addition health plans also benefit from avoiding costly emergency room visits such that these payers are increasing looking to promote AL living for their members as a means to improve their care. Reporting quality measures Many of these care elements are included in the quality measures being reporting by ALCs. This is especially needed because one can not always get a sense of the quality of care services through a simple walk through of the facility. So while touring an ALC it is critical to get a sense of the environment, given the significance of this investment and life changing move many older adults will need to look to quantitative quality assessments of the facilities in which they are interested. To this end, several groups are working to provide AL consumers a comprehensive system for supporting their decision-making. The Agency of Healthcare Research and Quality (AHRQ) has identified private accreditation organizations, state regulatory systems, consumer advocacy organizations, assisted living providers, who along with the Federal
Government supply information to help consumers navigate the wide range of assisted living offerings. Although there is not a standardized method for assessing the quality of assisted living AHRQ has identified three means available: state licensing and inspections, investigations and complaint monitoring by state ombudsman programs, and private voluntary accreditation surveys.3 Although states license, certify, and inspect assisted living these inspections differ significantly both within and among states, in part because of the lack of a uniform definition of assisted living. A National Academy for State Health Policy (NASHP) survey of state licensing officials noted that the most common areas of deficiencies included medication issues, quality of staff, quantity of staff, inadequate care and recordkeeping, admission/discharge issues, access to medical care, abuse, and billing issues. Many of these deficiencies directly tie back to nursing issues. Several states have adopted a “level of service licensure model” designed to provide information for consumer choice. These models, established in Idaho, Maryland, and other states, distinguish the levels of health care provided and the type and needs of resident services that the facility can accommodate. This can assist a potential AL resident and their family assessing the services available within a facility and related costs. State initiatives to systematically measure resident experience in long-term care facilities (including assisted living) are in an early developmental stage. Some states have developed innovative assisted living programs for residents. For example, Florida’s Department of Elder Affairs (2003) sponsors a “find a facility” Web site to allow public access to information (available at http://www. floridaaffordableassistedliving.org/). Texas enacted a law that requires assisted living facilities to provide a standardized report of information such as staffing, discharge criteria, charges, etc., which would allow consumers to compare facilities (GAO, 2004). The Texas Department of Aging and Disability Services (2005) sponsored Web site is http://facilityquality.dhs.state.tx.us. The Federal Older Americans Act (2000) requires that all states have an Ombudsman Program to advocate for and address complaints from residents in long-term care, including assisted living. According to data from the 2003 National Ombudsman Reporting System, the most frequent complaints involving assisted living (board and care) involve medication administration, menu quality, discharge eviction planning/notice, dignity/respect of staff, and equipment/building problems (Administration on Aging, 2004). Here nursing staff can be of assistance especially with regards to medication administration, dignity/respect and discharge determination of AL residents. Beyond state initiatives in recognizing AL quality, there are a number of outside accrediting bodies. The main accrediting bodies for assisted living facilities are the Commission on Accreditation of Rehabilitation Facilities (CARF) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Both organizations implemented their assisted living programs in 2000 and provide information regarding the results of facility surveys through their Web sites. These organizations evaluate similar areas, e.g., resident rights, continuity and coordination of services, resident education, and health promotion. The JCAHO accreditation process uniquely includes infection control. Currently only a small number of ALCs seek accreditation. Based on the GAO estimate of 36,000 U.S. assisted living facilities, less than 1 percent of the total industry is accredited by one of these two private accreditation organizations. Even if an ALC does not seek formal accreditation, knowing the standards of accreditation can be used to identify focus areas for the facility. The CARF accreditation standards are divided into three main sections:
R.G. Stefanacci, D. Haimowitz / Geriatric Nursing 35 (2014) 65e68
- Business practices e Information management, resident rights, leadership, and legal requirements. - Process of assisted living e Philosophy and physical environment, continuity and coordination of services, policies and procedures, and resident needs assessments. - Assisted living e Medication administration, smoking policies, transportation, and other aspects of resident life (CARF, 2005). Of these sections, AL nursing staff could be drawn to focus on medication administration as well as the continuity and coordination of services. JCAHO provides even more detail on its AL accreditation standard as it organizes its accreditation standards into 12 sections. The following is a list of the major dimensions covered and a brief overview of the content of each of the standards. Consumer protection and rights and assisted living community ethics e Improve resident outcomes by recognizing and respecting resident rights; identify the need to recognize residents as individuals with different needs; emphasize dignity, quality of life, and ethical behavior. Continuity of services e Define, shape, and sequence processes and activities that maximize coordination of services and minimize the need to move; address issues that arise prior to arriving at the assisted living community, during move-in, during time spent in the community, and while transfers take place. Assessment and reassessment e Determine the services to be provided by the community to meet the needs of the resident; assess each resident’s service needs upon move in or when those needs change; collect and analyze data to make these assessments and inform decisions regarding care plans. Resident services e Provide individualized, planned, appropriate services in settings appropriate to the resident’s needs; maintain a resident-specific planning process; implement the planned services; monitor resident response to services; modify the service plan based on reassessment, changes in the type or level of services needed, and the resident’s need for further services. Resident education e Improve resident outcomes by providing information that meets the resident’s learning needs, promotes healthy behavior, and allows residents to make informed decisions about services. Health and wellness promotion e Address maintaining resident’s health, maintaining and improving function, preventing injuries, and avoiding or delaying the deterioration of residents’ health status associated with chronic and degenerative diseases. Performance improvement e Systematically monitor, analyze, and improve its performance; monitor performance through collecting data, analyzing current data, and improving and sustaining improvements. Leadership e Plan, direct, coordinate, provide, and improve services that respond to residents’ changing needs and help them to remain in the community. Managing the environment e Provide a safe, functional, supportive, and effective home environment for residents, staff, and others in the community; conduct ongoing master planning, education, standards development, and implementation plans. Human resources management e Identify and provide the right number of competent staff to meet the needs of residents served by the community; plan, provide competent staff, assess and maintain staff competence, and provide an educational work environment.
67
Information management e Obtain, manage, and use information to improve resident outcomes and individual and community performance; manage resident applications, resident assessments, service-planning documentation, actual services provided, financial information, organization improvement information, billing information, and statistical information. Prevention and control of infections e Identify and reduce the risks of acquiring and transmitting infections among residents, visitors, employees, and contract services staff (JCAHO, 2005). While as with CARF, JCAHO focus includes medication administration and coordination of services, JCAHO goes into greater detail by including health and wellness promotion as well as prevention and control of infections. These four areas should be considered standard focus areas for any AL nursing staff whether or not one is seeking formal accreditation, as these will be the nursing AL areas that residents and potential residents hold the facility responsible. Beyond the states and outside accreditation groups CMS is also working to establish quality measures in ALs. A first set of quality indicators for assisted living has been developed as an extension of the nursing home version of the Resident Assessment Instrument (RAI), which includes information from the Minimum Data Set (MDS). Process-oriented indicators include providing needed services, good care practices, poor care practices, percentage of residents with little or no activities, and percentage of residents with multiple psychotropic drugs. The only outcome-oriented quality indicator that has been developed is the percentage of residents with falls. The editors of Consumer Reports published a guide to help consumers select long-term care services, including assisted living. This guide suggests that the prospective consumer review materials, compile questions, and make observations during site visits to assess the following: Staff rapport with residents. Signs of resident life and energy in the facility. How well the facility accommodates to the prospective resident’s needs. Level of oversight. Contractual terms/rules. Admissions process and application. Package of services, including rates and rate increases. Staff training based on agency licensing specifications. Activities offered. Kinds of services offered, such as transportation, housekeeping, laundry, meals, privacy. Type of medical care, including ability to see their personal physician. Medication administration and care plan. Transfer criteria. How they accommodate increasing frailty. The physical environment. All of the current types of informationdincluding consumer checklists, quality indicators, marketing materials, and other resourcesdcan be used to inform additional efforts to provide more objective, comprehensive, and readily acceptable materials to consumers. Much of the focus for these assessments is based on the quality of AL nursing staff which can be the critical differentiator of quality within any ACL. Avoiding the hospital Once an older adult has made the decision to become a resident of an ALC, most hope that they will be able to age in place rather
68
R.G. Stefanacci, D. Haimowitz / Geriatric Nursing 35 (2014) 65e68
than be forced to leave for another site of care. This is one of the founding principles of AL, to promote aging in place. Despite this, an extremely high percentage of residents are unable to do that, instead being transferred to another facility. But before the decision is made to transfer a resident out of their AL home because the facility does not have the ability for care at the level needed, the ALC should consider the opportunity of bringing in services. These services include acute care services such as the hospital at home project, advanced telemedicine, and hospice. These services can complement the ALC’s own staff in being able to care for a resident in their home rather than the hospital. When an acute issue arises there is typically not a physician available in the ALC so often times the resident is forced to the emergency room followed by an admission. An alternative to this approach is advanced telemedicine. Systems are now available that provide acute hospital-level care to AL residents. One such system utilizes state-of-the-art telemedicine technology to interview, examine and treat SNF patients after hours. By treating patients on site, the AL can avoid unnecessary hospitalizations, improve clinical outcomes, and increase resident and caregiver satisfaction. Once assessed and stabilized a treatment plan can be carried out in the ALC rather than the hospital. One program to provide this hospital level of care is the Hospital at Home program. The Hospital at HomeÒ was developed by Johns Hopkins School of Medicine as an innovative model providing hospital-level care in a patient’s home as a full substitute for acute hospital care. The program has demonstrated itself as a tool to cost-effectively treat acutely ill older adults, while improving patient safety, quality, and satisfaction. The program is offered to patients who require hospital admission for certain diseases, such as community-acquired pneumonia, congestive heart failure, chronic obstructive pulmonary disease, and cellulitis which are common conditions for AL residents.
Patients who meet specific medical eligibility criteria can receive hospital-level care e including diagnostic tests and treatment therapies from doctors and nurses e in their own home. Of course there are times when rather than acute care, providing palliative end of life care is the focus. In these situations hospice can be brought into the AL to allow the resident to remain in their home. A hospice assisted living program enables a hospice program to bring their particular expertise to residents. The program’s purpose is to allow residents in the advanced stages of illness to remain in familiar and supportive surroundings while receiving palliative (comfort-focused) care. Hospice enhances the specialized expertise of the AL staff with the care, emotional support and guidance residents and their families need during this distressing time. This can have a dramatic impact on an AL resident’s ability to remain comfortably in their home. In the end while finance and traditional marketing may play a role in getting residents into an ALC it is really the AL nursing staff that will get them to stay there. This will result in the realization that the most important sales force for any ALC is its nursing staff and the assistance they can provide in keeping residents healthy. Of course this comes with enormous responsibilities for the AL nursing staff to truly assist in the process of successful aging. In doing so those nurses will find great satisfaction for themselves and great success for their facility. References 1. http://www.whitehouse.gov/health-care-meeting/proposal/titleviii; Accessed 09.11.13. 2. http://www.ltccommission.senate.gov/Commission%20on%20Long-Term%20Ca re%20-%20Final%20Report%20-%209-18-13.pdf; Accessed 09.11.13. 3. http://www.ahrq.gov/professionals/systems/long-term-care/resources/facilities/ ltcscan/ltc4.html; Accessed 09.11.13.
Contents lists available at ScienceDirect
Geriatric Nursing journal homepage: www.gnjournal.com
Assisted Living Column
Richard G. Stefanacci
Dan Haimowitz
The ins and outs of ALCs Richard G. Stefanacci, DO, MGH, MBA, AGSF, CMD a, b, c, *, Dan Haimowitz, MD, CMD, FACP d, e, f a
Health Policy & Public Health, University of the Sciences in Philadelphia, PA, USA The Access Group, USA Mercy LIFE, Philadelphia, PA, USA d Private Practice, Levittown, PA, USA e Arden Courts of Yardley, PA, USA f Brunswick at Attleboro, Langhorne, PA, USA b c
Financial survival for Assisted Living Communities (ALCs) is based in large part on its occupancy rates. In basic terms this level is based on getting AL residents into the facility and keeping them there. While the AL nursing staff may think that this number game is solely the responsibility of the bean counters within the ALC, this thinking would be wrong. ALCs have come a long way from their start when they were birthed from hotel companies thinking that ALCs were an extension of the hospitality business. These companies, Marriott and Hyatt, are no longer in the AL business. Instead, companies with a foundation in health care are now firmly in charge. This is because AL residents today seem more interested in assistance in their health care than in the hospitality services being offered, although the variety and quality of meals still ranks very high in AL selection decisions. With this focus on health care it’s clear that demonstrating the value of high quality medical care along with preventive services can only be accomplished with the leadership and support of the AL nursing staff. In this article we will examine the payment for ALCs, what it takes to get a resident in and keep them within the facility. When thinking about the role of nurses in getting and keeping residents one must start with understanding how ALs are paid.
* Corresponding author. Health Policy & Public Health, University of the Sciences in Philadelphia, PA, USA. E-mail address: [email protected] (R.G. Stefanacci). 0197-4572/$ e see front matter Ó 2014 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.gerinurse.2013.11.007
Financing ALCs are primarily paid privately through individual’s own resources. In recent years these resources have taken a significant hit as home values and personal assets have markedly lessened due to the weakened economy. However, beyond one’s personal resources there are a growing number of avenues to fund ALCs. Some of these include LTC insurance or state programs that look to avoid the expense of skilled nursing facilities some of which can cost 3e4 times that of an ALC. Congress had attempted within the Affordable Care Act to introduce an LTC option for Americans. This was included under the Community Living Assistance Services and Supports Act (or CLASS Act),1 a U.S. federal law, enacted as Title VIII of the Patient Protection and Affordable Care Act. The CLASS Act would have created a voluntary and public long-term care insurance option for employees, but in October 2011 the Obama administration announced this insurance option was unworkable and would therefore be dropped. The CLASS Act was formally repealed on January 1, 2013. Although the CLASS Act failed, the Commission on Long-Term Care issued a report to Congress in September 2013 providing recommendations for long-term care reform.2 They issued two alternative approaches of financing long-term services and supports (LTSS) reform: 1) via private options and 2) via a public, social insurance option. The two public options were 1) creating a comprehensive Medicare LTSS benefit or 2) creating a basic LTSS benefit as part of Medicare Part A or in a new public program. A public option through Medicare would significantly increase the
66
R.G. Stefanacci, D. Haimowitz / Geriatric Nursing 35 (2014) 65e68
number of older adults able to afford LTC services including AL services. Beyond LTC insurance there are also state programs that are looking to provide coverage for AL care. These include opportunities through Home & Community based waivered programs and managed care programs such as Managed Medicaid and PACE. All of these programs look to move care to outside of the skilled nursing facility to alternative sites including AL. Whether it is the decision of the resident or families using their own funds or an outside organization like an MCO making the call creating and demonstrating value is critical. Assisted care Of course even with a source of funds either personal or public, older adults still need to decide if a particular ALC is right for them. To that end, an increasing number of older adults are relying on the variety and quality of Clinical Services to base their decision. These services typically fall into three categories: acute care, maintaining, and chronic disease management. On the chronic disease state management side these services include the management of diabetes, CHF, COPD and Alzheimer’s diseases. Many AL residents suffer from chronic comorbid conditions; in fact, it is often a progression of these conditions that prompts their move to an ALC. Because of this, ALCs are evaluated by potential residents on their ability to deliver quality chronic disease management. This management relies on careful medication management, monitoring of red flags, regular primary care provider follow-up and preventive care initiatives. These initiatives were identified as needed steps to prevent avoidable hospitalizations from occurring. As a result ALCs are well served in establishing comprehensive chronic disease management programs that incorporate these elements. Of course, sometimes acute care services are needed in AL to avoid an ER visit. Acute care services within an ALC can run the gambit from a physician’s office to a provider that can make urgent house calls. Technology is making it such that providers can make virtual or telemedicine bedside calls to AL residents in need of acute care services. One recently introduced services that provide acute hospital-level care to patients residing in LTC facilities. Physicians can now use state-of-the-art telemedicine technology to interview, examine and treat LTC residents when their usual physicians are not available. By treating patients on site, an AL facility can avoid unnecessary hospitalizations, improve clinical outcomes, and increase resident and family satisfaction. In addition health plans also benefit from avoiding costly emergency room visits such that these payers are increasing looking to promote AL living for their members as a means to improve their care. Reporting quality measures Many of these care elements are included in the quality measures being reporting by ALCs. This is especially needed because one can not always get a sense of the quality of care services through a simple walk through of the facility. So while touring an ALC it is critical to get a sense of the environment, given the significance of this investment and life changing move many older adults will need to look to quantitative quality assessments of the facilities in which they are interested. To this end, several groups are working to provide AL consumers a comprehensive system for supporting their decision-making. The Agency of Healthcare Research and Quality (AHRQ) has identified private accreditation organizations, state regulatory systems, consumer advocacy organizations, assisted living providers, who along with the Federal
Government supply information to help consumers navigate the wide range of assisted living offerings. Although there is not a standardized method for assessing the quality of assisted living AHRQ has identified three means available: state licensing and inspections, investigations and complaint monitoring by state ombudsman programs, and private voluntary accreditation surveys.3 Although states license, certify, and inspect assisted living these inspections differ significantly both within and among states, in part because of the lack of a uniform definition of assisted living. A National Academy for State Health Policy (NASHP) survey of state licensing officials noted that the most common areas of deficiencies included medication issues, quality of staff, quantity of staff, inadequate care and recordkeeping, admission/discharge issues, access to medical care, abuse, and billing issues. Many of these deficiencies directly tie back to nursing issues. Several states have adopted a “level of service licensure model” designed to provide information for consumer choice. These models, established in Idaho, Maryland, and other states, distinguish the levels of health care provided and the type and needs of resident services that the facility can accommodate. This can assist a potential AL resident and their family assessing the services available within a facility and related costs. State initiatives to systematically measure resident experience in long-term care facilities (including assisted living) are in an early developmental stage. Some states have developed innovative assisted living programs for residents. For example, Florida’s Department of Elder Affairs (2003) sponsors a “find a facility” Web site to allow public access to information (available at http://www. floridaaffordableassistedliving.org/). Texas enacted a law that requires assisted living facilities to provide a standardized report of information such as staffing, discharge criteria, charges, etc., which would allow consumers to compare facilities (GAO, 2004). The Texas Department of Aging and Disability Services (2005) sponsored Web site is http://facilityquality.dhs.state.tx.us. The Federal Older Americans Act (2000) requires that all states have an Ombudsman Program to advocate for and address complaints from residents in long-term care, including assisted living. According to data from the 2003 National Ombudsman Reporting System, the most frequent complaints involving assisted living (board and care) involve medication administration, menu quality, discharge eviction planning/notice, dignity/respect of staff, and equipment/building problems (Administration on Aging, 2004). Here nursing staff can be of assistance especially with regards to medication administration, dignity/respect and discharge determination of AL residents. Beyond state initiatives in recognizing AL quality, there are a number of outside accrediting bodies. The main accrediting bodies for assisted living facilities are the Commission on Accreditation of Rehabilitation Facilities (CARF) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Both organizations implemented their assisted living programs in 2000 and provide information regarding the results of facility surveys through their Web sites. These organizations evaluate similar areas, e.g., resident rights, continuity and coordination of services, resident education, and health promotion. The JCAHO accreditation process uniquely includes infection control. Currently only a small number of ALCs seek accreditation. Based on the GAO estimate of 36,000 U.S. assisted living facilities, less than 1 percent of the total industry is accredited by one of these two private accreditation organizations. Even if an ALC does not seek formal accreditation, knowing the standards of accreditation can be used to identify focus areas for the facility. The CARF accreditation standards are divided into three main sections:
R.G. Stefanacci, D. Haimowitz / Geriatric Nursing 35 (2014) 65e68
- Business practices e Information management, resident rights, leadership, and legal requirements. - Process of assisted living e Philosophy and physical environment, continuity and coordination of services, policies and procedures, and resident needs assessments. - Assisted living e Medication administration, smoking policies, transportation, and other aspects of resident life (CARF, 2005). Of these sections, AL nursing staff could be drawn to focus on medication administration as well as the continuity and coordination of services. JCAHO provides even more detail on its AL accreditation standard as it organizes its accreditation standards into 12 sections. The following is a list of the major dimensions covered and a brief overview of the content of each of the standards. Consumer protection and rights and assisted living community ethics e Improve resident outcomes by recognizing and respecting resident rights; identify the need to recognize residents as individuals with different needs; emphasize dignity, quality of life, and ethical behavior. Continuity of services e Define, shape, and sequence processes and activities that maximize coordination of services and minimize the need to move; address issues that arise prior to arriving at the assisted living community, during move-in, during time spent in the community, and while transfers take place. Assessment and reassessment e Determine the services to be provided by the community to meet the needs of the resident; assess each resident’s service needs upon move in or when those needs change; collect and analyze data to make these assessments and inform decisions regarding care plans. Resident services e Provide individualized, planned, appropriate services in settings appropriate to the resident’s needs; maintain a resident-specific planning process; implement the planned services; monitor resident response to services; modify the service plan based on reassessment, changes in the type or level of services needed, and the resident’s need for further services. Resident education e Improve resident outcomes by providing information that meets the resident’s learning needs, promotes healthy behavior, and allows residents to make informed decisions about services. Health and wellness promotion e Address maintaining resident’s health, maintaining and improving function, preventing injuries, and avoiding or delaying the deterioration of residents’ health status associated with chronic and degenerative diseases. Performance improvement e Systematically monitor, analyze, and improve its performance; monitor performance through collecting data, analyzing current data, and improving and sustaining improvements. Leadership e Plan, direct, coordinate, provide, and improve services that respond to residents’ changing needs and help them to remain in the community. Managing the environment e Provide a safe, functional, supportive, and effective home environment for residents, staff, and others in the community; conduct ongoing master planning, education, standards development, and implementation plans. Human resources management e Identify and provide the right number of competent staff to meet the needs of residents served by the community; plan, provide competent staff, assess and maintain staff competence, and provide an educational work environment.
67
Information management e Obtain, manage, and use information to improve resident outcomes and individual and community performance; manage resident applications, resident assessments, service-planning documentation, actual services provided, financial information, organization improvement information, billing information, and statistical information. Prevention and control of infections e Identify and reduce the risks of acquiring and transmitting infections among residents, visitors, employees, and contract services staff (JCAHO, 2005). While as with CARF, JCAHO focus includes medication administration and coordination of services, JCAHO goes into greater detail by including health and wellness promotion as well as prevention and control of infections. These four areas should be considered standard focus areas for any AL nursing staff whether or not one is seeking formal accreditation, as these will be the nursing AL areas that residents and potential residents hold the facility responsible. Beyond the states and outside accreditation groups CMS is also working to establish quality measures in ALs. A first set of quality indicators for assisted living has been developed as an extension of the nursing home version of the Resident Assessment Instrument (RAI), which includes information from the Minimum Data Set (MDS). Process-oriented indicators include providing needed services, good care practices, poor care practices, percentage of residents with little or no activities, and percentage of residents with multiple psychotropic drugs. The only outcome-oriented quality indicator that has been developed is the percentage of residents with falls. The editors of Consumer Reports published a guide to help consumers select long-term care services, including assisted living. This guide suggests that the prospective consumer review materials, compile questions, and make observations during site visits to assess the following: Staff rapport with residents. Signs of resident life and energy in the facility. How well the facility accommodates to the prospective resident’s needs. Level of oversight. Contractual terms/rules. Admissions process and application. Package of services, including rates and rate increases. Staff training based on agency licensing specifications. Activities offered. Kinds of services offered, such as transportation, housekeeping, laundry, meals, privacy. Type of medical care, including ability to see their personal physician. Medication administration and care plan. Transfer criteria. How they accommodate increasing frailty. The physical environment. All of the current types of informationdincluding consumer checklists, quality indicators, marketing materials, and other resourcesdcan be used to inform additional efforts to provide more objective, comprehensive, and readily acceptable materials to consumers. Much of the focus for these assessments is based on the quality of AL nursing staff which can be the critical differentiator of quality within any ACL. Avoiding the hospital Once an older adult has made the decision to become a resident of an ALC, most hope that they will be able to age in place rather
68
R.G. Stefanacci, D. Haimowitz / Geriatric Nursing 35 (2014) 65e68
than be forced to leave for another site of care. This is one of the founding principles of AL, to promote aging in place. Despite this, an extremely high percentage of residents are unable to do that, instead being transferred to another facility. But before the decision is made to transfer a resident out of their AL home because the facility does not have the ability for care at the level needed, the ALC should consider the opportunity of bringing in services. These services include acute care services such as the hospital at home project, advanced telemedicine, and hospice. These services can complement the ALC’s own staff in being able to care for a resident in their home rather than the hospital. When an acute issue arises there is typically not a physician available in the ALC so often times the resident is forced to the emergency room followed by an admission. An alternative to this approach is advanced telemedicine. Systems are now available that provide acute hospital-level care to AL residents. One such system utilizes state-of-the-art telemedicine technology to interview, examine and treat SNF patients after hours. By treating patients on site, the AL can avoid unnecessary hospitalizations, improve clinical outcomes, and increase resident and caregiver satisfaction. Once assessed and stabilized a treatment plan can be carried out in the ALC rather than the hospital. One program to provide this hospital level of care is the Hospital at Home program. The Hospital at HomeÒ was developed by Johns Hopkins School of Medicine as an innovative model providing hospital-level care in a patient’s home as a full substitute for acute hospital care. The program has demonstrated itself as a tool to cost-effectively treat acutely ill older adults, while improving patient safety, quality, and satisfaction. The program is offered to patients who require hospital admission for certain diseases, such as community-acquired pneumonia, congestive heart failure, chronic obstructive pulmonary disease, and cellulitis which are common conditions for AL residents.
Patients who meet specific medical eligibility criteria can receive hospital-level care e including diagnostic tests and treatment therapies from doctors and nurses e in their own home. Of course there are times when rather than acute care, providing palliative end of life care is the focus. In these situations hospice can be brought into the AL to allow the resident to remain in their home. A hospice assisted living program enables a hospice program to bring their particular expertise to residents. The program’s purpose is to allow residents in the advanced stages of illness to remain in familiar and supportive surroundings while receiving palliative (comfort-focused) care. Hospice enhances the specialized expertise of the AL staff with the care, emotional support and guidance residents and their families need during this distressing time. This can have a dramatic impact on an AL resident’s ability to remain comfortably in their home. In the end while finance and traditional marketing may play a role in getting residents into an ALC it is really the AL nursing staff that will get them to stay there. This will result in the realization that the most important sales force for any ALC is its nursing staff and the assistance they can provide in keeping residents healthy. Of course this comes with enormous responsibilities for the AL nursing staff to truly assist in the process of successful aging. In doing so those nurses will find great satisfaction for themselves and great success for their facility. References 1. http://www.whitehouse.gov/health-care-meeting/proposal/titleviii; Accessed 09.11.13. 2. http://www.ltccommission.senate.gov/Commission%20on%20Long-Term%20Ca re%20-%20Final%20Report%20-%209-18-13.pdf; Accessed 09.11.13. 3. http://www.ahrq.gov/professionals/systems/long-term-care/resources/facilities/ ltcscan/ltc4.html; Accessed 09.11.13.
